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RMAC Online Intake Form

Please choose one of the following options to send your completed Rocky Mountain Autism Center Online Intake Form:

Complete Online Intake Form and press Submit button
Print blank form, complete form and fax to 720-962-0678
Print blank form, complete form, scan and e-mail to info@rockymountainautismcenter.com

Referred by *

Referral Practice/Agency Name *

Referral Practice/Agency Phone # *

Parent/Guardian (first and last name) *

Parent/Guardian Phone #(s) *

Parent/Guardian Email Address(es) *

Child's Name (first and last name) *

Child's Primary Address (Street, City, State, Zip Code) *

Child's Date of Birth [mm/dd/yyyy] *

Child's School/School District *

Child's Primary Diagnosis *

Child's Primary Physician *

RMAC Services Requested: *: Speech Language Therapy
Occupational Therapy
Behavioral Therapy
Individual (One on One Intervention)
Group Intervention

Funding Source (Private Pay, Insurance, Medicaid, CWA, CES, SLS) *

Comments or Concerns *

Fields marked with * are required.

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