Straith Behavioral Health - Request for Information

Request Information:

Parent/Guardian Name

Phone Number

Address

City

State

Zip Code

Name of Individual Receiving Services

Individual Receiving Services Date of Birth

Insurance Type or Funding Source

Upload Insurance Cards

Upload Physician Referral

Do you have a secondary funding source? (If yes, please specify)

Program Model Interested In:

Does the individual receiving services have an autism diagnosis? (If yes, please upload below)

If the individual does not have an autism diagnosis, are you currently seeking a diagnosis from a diagnosing provider?