top of page

Home
About
Services
Insurance
Resource Store
Contact
Intake
Tienda

Client Intake

Tell us about your child and your family. We'll review your request and contact you as soon as possible.

Please complete the form below so we can understand your child's needs and verify your insurance benefits. Fields marked with * are required.

Please do not include sensitive medical information in this form. When we contact you, we'll provide a secure way for you to send us your documents and complete the clinical consent forms.

Request Services

Fields marked with * are required.

Child information

Child's first name*

Child's last name*

Child's date of birth*

Month

Day

Year

Parent / guardian information

Parent or guardian first name*

Parent or guardian last name*

Email address*

Phone number*

Home address*

City*

State*

ZIP code*

Alternate contact name

Alternate contact phone or email

Services requested

Services requested (select all that apply)*

ABA Therapy

Parent Training

Speech Therapy

Occupational Therapy

Psychological Evaluation

Respite

Habilitation

Other

Preferred spoken language*

Preferred written language*

Clinical and school information

Primary care provider

Provider phone number

School or daycare

School schedule

Current services

Current provider or agency

Insurance information

Insurance company*

Policyholder name*

Policyholder date of birth*

Month

Day

Year

Policyholder employer

Secondary insurance (if any)

Care coordination

Care coordinator name

Care coordinator email or phone

Consent

I understand and consent to the following*

I authorize Real Academy Behavior Therapy to contact me about this request.

I understand that this form does not include clinical documents or policy numbers, and that this information will be completed later through a secure channel.

I understand I have the right to refuse or withdraw consent at any time.

Send Us Your Documents Securely

This form is the first step in the application process. To protect your child's privacy, we do not collect insurance cards, diagnostic evaluations, or prescriptions through this form. Once we receive your application, we will send you an email outlining the next steps and provide you with a secure way to submit your documents and complete the clinical consent forms.

Building Skills, Changing Lives

bottom of page