Request Services

Parent/Guardian's First and Last Name

Parent/Guardian's e-mail address

Parent/Guardian's Phone number

Parent/Guardian Home Address

Preferred Method of Contact

Phone

You agree to recieve informational messages (appointment reminders, account notifications, etc.) from Lasting Behavioral Solutions. Message frequency varies. Message and data rates may apply. For help, reply HELP or email us at officeadmin@lastingbehavioralsolutions.net. You can opt out at any time by replying STOP. See Terms & Conditions /SMS Privacy Policy below

Yes

Child's First and Last Name

Child's Date of Birth

(Month/Date/Year)

Do you currently have insurance? Please note that an Autism Diagnosis is required for insurance coverage. An Autism Diagnosis is not required with the Regional Center

Yes

Name of Insurance Carrier LBS in network with commercial carriers :

Anthem BCBS

Magellan

Regional Center of Orange County

Aetna

CalOptima / MediCal

Private Pay

Optum / United Healthcare

Other

Does your child have a diagnosis of Autism from a medical doctor? Please note that an Autism Diagnosis is required for most insurances

Yes

Evaluation Pending

What services are you requesting

Clinic Based Services

In Home ABA Therapy

Parent-Led ABA Therapy / Family Coaching

How did you hear about us?

Pediatrician / Physician

Self Referral

School Referral

Friend

Insurance

Google

None of the above

Reason For Referral

Does your child take any medications (Include frequency and Dosage below)

Upload the Front and Back of your insurance card

Add file

Please upload a file

Date of Birth for Policy Holder (if not under child)

Month/Date/Year

"Messaging Terms & Conditions: You agree to receive informational messages (appointment reminders, account notifications, etc.) from Lasting Behavioral Solutions. Message frequency varies. Message and data rates may apply. For help, reply HELP or email us at officeadmin@lastingbehavioralsolutions.net. You can opt out at any time by replying STOP.

"Mobile SMS Messaging," Private Policy: Information collected: We may collect information, such as name, phone number, and email address. Use of information collected: We may use information we collect to perform the services requested including billing, customer service, appointment reminders and other administrative requests.

Sharing information collected: Mobile information will not be shared with third parties/affiliates for marketing/promotional purposes. This includes text messaging opt-in data and consent.

As current or prospective customer, you understand that you can text us STOP at any time to opt out of receiving SMS text messages from us. You can text HELP at any time to receive help. You understand that the messaging frequency may vary. Messaging & data rates may apply.

All policies are followed as per CTIA guidelines 5.2.1. At any time if you want your information to be removed, you can contact us via our email address or regular mail.

Your information will be encrypted.

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Intake Request Form

Intake Request Form