Interest Form

How were you referred to us?*

MCO
Autism Resource Specialist
Self or Family
Physician/Healthcare Provider
Other Provider Agency
Other

County of residence*

Participant name*

Date of birth*

Age*

Please share your ethnicity:*

Asian
Black/African American
Caucasian/White
Hispanic or Latino
Native American or Other Indigenous
Native Hawaiian or Pacific Islander
Two or More Races
Other/Unknown
Prefer not to answer

Preferred Language in Your Home*

English
Spanish
Other

Autism diagnosis*

Yes
No
Uncertain

Please attach most recent and relevant diagnostic assessments.

Drop files here or

Max. file size: 300 MB.

Acceptable formats include: PDF, Word Doc, JPG, PNG, and GIF

Home Address (street, city, ZIP code)*

Primary Phone*

Email*

Parent/Guardian(s) Full Name(s)*

Funding source for ABA services*

Medicaid Standard Plan
Medicaid Tailored Plan
Private Health Insurance
Private Pay

Medicaid Standard Plan Name*

Healthy Blue
United Healthcare of NC
WellCare
AmeriHealth Caritas
Carolina Complete Health

Please enter health insurance company name and plan information (subscriber #)*

Use the "select" icon to upload front and back copies of your insurance card(s)

Drop files here or

Max. file size: 300 MB.

The LifeLong Interventions program is rooted in the principles of Applied Behavior Analysis (ABA). The main goals of the program are typically to promote skill development in such areas as socialization, functional communication, and activities of daily living, and to reduce problem behavior. Goals are identified via comprehensive clinical assessment and in coordination with parent/caregiver/client’s identified areas of need.

Our program is intensive in nature and requires a minimum of 10 direct service hours per week. Session durations typically range from 2 to 4 hours.

This direct service typically occurs in the home, but may also be provided in other settings as appropriate. Direct service is provided by a Registered Behavior Technician (RBT) who is closely supervised by a Board Certified Behavior Analyst (BCBA). The BCBA is supervised by a PhD-level clinical psychologist who oversees all clinical programs within the Clinical Department.

Parent/caregiver training and ongoing involvement is a crucial, required component of this service. In most cases, an adult over the age of 18 is required to be in the home during service delivery. It is also important to note that RBTs do not transport clients in the community as a part of this service.

Your relationship to participant*

Briefly describe reason(s) for seeking services*

The LifeLong Interventions program is Monday - Friday on a block schedule. Please select the block(s) that your participant is available*

Select All
Mornings: 8:30 a.m. - Noon
Mid-days: 12:30pm-3:30pm
Afternoon: 4pm-6:30pm

Today's date*

For additional questions, please contact Melissa Roper (Clinical Intake Coordinator) at mroper@autismsociety-nc.org or 919-865-5077.

*Please update us immediately with any changes to your insurance information, session schedule availability, etc.