Request Services
Please use the form below to request new services. We cannot always guarantee there will be an immediate spot available for your child in your selected program(s) but either way, an administrator will contact you as soon as possible.
Child's Name
*
First Name
Last Name
Child's Birthdate
*
-
Month
-
Day
Year
Date
Client's Age
*
Client's Gender
*
Male
Female
Diagnosis or primary concerns
*
Please check any Home and Community-Based services you are interested in
*
Habilitation
Respite
Attendant Care
Unsure
None
Do you already have one or more providers in mind?
*
Yes, I personally know one or more providers I'd like to match with
No, I do not have a provider in mind, please match me with one or more to interview
Please list the provider(s) you would like matched with:
If your child is 2 - 14 years of age with a diagnosis of autism, would you like information about our ABA Autism Early Learning Center or our ABA After School Program?
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Yes, I'm interested in the Early Learning Center for ages 2 - 6
Yes, I'm interested in the After School Program for ages 6 - 14
No or N/A
Cross Streets and City (to help us determine our availability in your area)
*
Please list the times requested for each day of the week
*
Rows
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Times Requested
Attributes of the child or a potential provider to help us find a match (i.e. Child is a runner, Provider must be familiar with GFCF diet, etc)
*
Preferred language in the home
*
Provider preference
*
Female
Male
Either
Please list any indoor pets
Any household member allergies? (example - Sister allergic to peanuts)
Funding Source(s)
*
D.D.D. Hours
Private Insurance
AHCCCS Plan
Unsure
DDD Support Coordinator
Private Insurance Company (Ex: Aetna, Blue Cross, etc)
AHCCCS Plan (ex: Mercy Care, United Community)
Person filling out form
*
First Name
Last Name
Relationship
*
Phone Number
*
-
Area Code
Phone Number
E-mail
*
Questions or Comments
Submit
Should be Empty: