Request PALS Services
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Location
Which PALS office would you like to receive services from? *
Respondent Information
I am a: 
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Respondent name: (first and last) *
Respondent email address: *
Respondent phone number: *
Client Information
Client's name: (first and last) *
Client's date of birth: *
Has the client received an autism diagnosis? *
Has the client received any other psychiatric diagnoses? 
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What insurance plan is the client covered by? *
Client's address (street# and city): *
Services Requested
What type of ABA services are you interested in? (check all that apply) *
Required
Please describe the client's current areas of need, and what kinds of support you feel may be helpful. *
Can we answer any questions regarding PALS services? 
Please list your child's current weekday schedule (times when your child IS NOT available for new services). *
How did you hear about PALS? (check all that apply)
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