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Client Interest Form
NOTE: Our service area is Henderson, South (east or west) Las Vegas & Boulder City, & we provide in-home services only
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* Indicates required question
Parent's name:
*
Your answer
Child's name:
*
Your answer
Child's age:
*
Your answer
Contact email:
*
Your answer
Contact phone:
*
Your answer
Preferred method of contact:
*
phone
email (please check your spam within 24-48 hours in case our response went there)
What insurance do yo have?
*
NV Medicaid (fee-for-service)
Molina Medicaid
Silver Summit Medicaid
Cigna
UHC/Optum
I am interested in private pay services
Other:
What services are you interested in?
*
Family training only (no RBT providing direct therapy)
Direct therapy with BCBA (limited DAYTIME hours only)
Direct therapy with RBT (limited DAYTIME hours only)
I'd like to go on the wait list for after school hours
I'd like to go on the wait list for weekend hours
Required
What is the biggest issue/difficulty that you'd like support with?
*
Your answer
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