Person Requesting Information Name of person requesting information Email Home Phone # Cell Phone # Are we allowed to leave a message or send an email? YesNo Purpose of inquiry/Presenting concern(s) Do you have diagnosis report within the last year (Required for ABA)? YesNo Services Requested ---ABA Services in SchoolAssessment for ABA ServicesConsultContinuation of ABA Services from another companyCounselingFloorTime™MCBIMusic TherapySpeech TherapySocial SkillsTutoringOther If Other selected, specify below (ABA Only) Is there accessible parking for therapists for home sessions? YesNo Availability Special Requests/Notes Patient information Name Age Date of birth Phone # Address Spoken Language(s) Diagnosis Insurance Name Insurance ID # Is there a secondary Insurance? YesNo Insurance phone number (800 or 888 # back of card) Regional Center UCI # R.C. Service Coordinator How did you hear about us? ---FriendHolding Hands ClientHolding Hands StaffInsurance CompanyOnlineThe Doctors ShowOther If Other selected, specify below If you are requesting services through your insurance, our Intake Department will need to verify your benefits. Please contact our insurance department for any questions 213-201-0448