Request for Services FormJudevine® provides many different services. Let us know what service we can provide for you! Please fill out the form below and we will review it to see what we can do for you and get back to you in a jiffy. •Explore possible enrollment in any of our programs. •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. Today's Date Date Format: MM slash DD slash YYYY Your name*Reason(s) for filling out this formSelect one or more* Assessment/Evaluation ABA Behavior Therapy Employment Day Program In-Home Behavioral Support Respite Parent Training Social Skills Individualized Supported Living (Residential) Functional Behavioral Assessment School or Individual Consultation Speech Therapy Other Tell us about your family memberIndividual's Legal Name* First Last Nickname if anyDate of Birth Date Format: MM slash DD slash YYYY 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?*YesNoTell us the Physician or Psychologist making the diagnosis First name Last name PhonePhysician's phone numberDescribe your family memberWhat are their problematic behavior(s)*(i.e. temper, focus, etc.)What are their skill deficits? (i.e. communication, social interaction, self-help, etc.)ParentsPlease indicate the guardian's name if its different from the parentsMother'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?*YesNoGuardian'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 InformationDMH/TCM Name First Last Phone NumberName of Insurance CarrierMedicaid NumberCurrent Services that are being ProvidedAre services currently being provided?(i.e. ABA at home or school, Speech, OT, etc.)School InformationDoes your child attend school?Additional InformationWhat 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 AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country This iframe contains the logic required to handle Ajax powered Gravity Forms.
