Request for Services Request for Services This form allows our staff to quickly gather information about your child, teen, or adult. After the form is submitted, someone from Judevine Center for Autism will contact you. "*" indicates required fields Your Name*Name of the person filling out this form. Relationship*Relationship to the individual seeking services. Requested Service(s)*Please select the services you are interested in receiving. General Information In-Home Behavioral Support Behavior Therapy Residential Parent Training Functional Behavior Assessment Assessment (ADOS, VB-MAPP) Evaluation School or Individual Consultation Day Program Employment Services Respite Social Skills Support Groups BCBA/BCaBA Supervision Special Education Other Other Service(s)* Individual InformationIndividual's Legal Name* First Last Date of Birth* Month Day Year Age*HiddenCalculated AgeIndividual's ageAddress*Individual's current address Street Address Address Line 2 City ZIP Code County* Does this individual attend school?* Yes No Grade LevelNonePreschoolKindergarten1st2nd3rd4th5th6th7th8th9th10th11th12thPost SecondaryOtherParent/Guardian Contact InformationName* First Last Phone*Email* Background InformationDoes the individual have an Autism Spectrum Disorder diagnosis?* Yes No Does the individual have any other diagnoses? Did the individual receive their diagnosis from a doctor or physician?* Yes No Doctor's Name* Doctor's Phone*Has the individual received funded services before?* Yes No How were these services funded?* Missouri Department of Mental Health Division of Developmental Disabilities Private Insurance Medicaid Private Pay Other Does the individual have a DMH Service Coordinator?* Yes No DMH Service Coordinator Name* Phone Number of DMH Service Coordinator*Does the individual have insurance?* Yes No Insurance Company Name* Name of Employer providing insurance Is the individual on Medicaid?* Yes No Medicaid number* Is the individual currently receiving services?* Yes No Current Services*Please list any services that are currently being provided (e.g. ABA at home or school, speech therapy, OT, etc.)Previous Services*Please list any services that were previously provided (e.g. ABA at home or school, speech therapy, OT, etc.)Has the individual previously received services?* Yes No Behaviors & NeedsBehaviorsDoes the individual exhibit any of the following behaviors? (check all that apply) Self-injurious behavior Physical aggression Property destruction Self-stimulatory behavior PICA Other Other Behaviors* Skill Deficits*What skill deficit(s) does the individual currently experience? (check all that apply) Communication Self-help Skills Life Skills Academic Pre-academic Social Skills Other Other Deficits* Additional InformationPlease describe any additional concerns or needs.Preferred location of services In-Home In Clinic In School How did you hear about Judevine Center for Autism?* Friend/Family Colleague Teacher/School Healthcare Professional Social Media Online Other Communication Exchange Between the Consumer/Legal Representative and the Provider The Judevine Center for Autism (Judevine hereafter) uses HIPAA compliant methods of electronic communication unless explicitly authorized by the consumer or legal representative.Compliant methods: HIPAA compliant methods of electronic communication include encrypted email and phone call. These methods are to protect health information during transmission and storage on personal electronic devices.Your Right: You may choose to communicate with Judevine in non-HIPAA compliant methods such as unencrypted email or SMS text messages. You may change your preferred method of communication at any time by submitting an updated Communication Preference Authorization form.Risks: Risks of using unencrypted email or SMS text message may include unauthorized 3rd parties could gain access to the information in the communication and use in a manner inconsistent with the law.We may use encrypted email during the Request for Services process. Do you give us permission to email you with encryption?* Yes No Per your authorization, we may use unencrypted email during the Request for Services process. Do you give us permission to use unencrypted email?* Yes No We may use phone calls during the Request for Services process. Do you give us permission to call you on the phone?* Yes No Per your authorization, we may use SMS text during the Request for Services process. Do you give us permission to text you?* Yes No HiddenAuthorizationsSelect all that apply We may use encrypted email during the Request for Services process. Do you give us permission to email you with encryption? We may use phone calls during the Request for Services process. Do you give us permission to call you on the phone? Per your authorization, we may use unencrypted email during the Request for Services process. Do you give us permission to use unencrypted email? Per your authorization, we may use SMS text during the Request for Services process. Do you give us permission to text you? Select AllPhoneThis field is for validation purposes and should be left unchanged.
