Request for Services | Judevine® Center for Autism

•Explore our services. Not all services are always available at all locations.
•Complete the Request for Services Form below and submit it to our office.
•This allows our clinical staff to quickly gather information about your child, teen, or adult.
•Upon receipt of the Request for Services Form we will contact you as soon as possible.

Today's Date

Your name*

Reason(s) for filling out this form

Select one or more*

Tell us about your family member

Individual's Legal Name*

First Last

Nickname if any

Date of Birth

Current Age*

Individual's Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

County of residence*

Does your family member have an autism diagnosis?*

Yes
No

Tell us the Physician or Psychologist making the diagnosis

First name Last name

Phone

Physician's phone number

Describe your family member

What are their problematic behavior(s)*

(i.e. temper, focus, etc.)

What are their skill deficits?

(i.e. communication, social interaction, self-help, etc.)

Parents

Please indicate the guardian's name if its different from the parents

Mother's name

First Last

Father's name

First Last

Guardian's name

First Last

Parent's Address

Same as individual's address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Is the address of the Guardian the same as the Parents?*

Yes
No

Guardian's Address

Street Address Address Line 2 City and County State / Province / Region ZIP / Postal Code

Parents’ or Guardian’s home phone number(s)*

Parents’ or Guardian’s cell number*

Parents’ or Guardian’s email address*

Funding Information

DMH/TCM Name

First Last

Phone Number

Name of Insurance Carrier

Medicaid Number

Current Services that are being Provided

Are services currently being provided?

(i.e. ABA at home or school, Speech, OT, etc.)

School Information

Does your child attend school?

Additional Information

What treatments have you tried?

How did you hear about Judevine®?

Check as many as are applicable

Friend
Colleague
Internet
Facebook
Professional Referral
other

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country