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 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 MM slash DD slash YYYY Your name* Reason(s) for filling out this formSelect one or more* Assessment/Evaluation ABA Behavior Therapy Early Intervention 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 any Date of Birth 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?* Yes No Tell 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?* 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 InformationDMH/TCM Name First Last Phone NumberName of Insurance Carrier Medicaid Number Current 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country