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	<title>Services archivo - Leaders Behavior ABA &amp; Counseling, LLC</title>
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	<link>https://leadersabatherapy.com/service/</link>
	<description>Behavior ABA &#38; Counseling</description>
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	<title>Services archivo - Leaders Behavior ABA &amp; Counseling, LLC</title>
	<link>https://leadersabatherapy.com/service/</link>
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	<item>
		<title>CHILD AND CAREGIVER SOCIAL GROUPS</title>
		<link>https://leadersabatherapy.com/service/child-and-caregiver-social-groups/</link>
		
		<dc:creator><![CDATA[admin]]></dc:creator>
		<pubDate>Sat, 04 Jul 2020 17:11:56 +0000</pubDate>
				<guid isPermaLink="false">http://capital.imithemes.com/demo1/?post_type=imi_services&#038;p=49</guid>

					<description><![CDATA[<p>Building social groups connections is a fantastic way for caregivers to learn parenting skills and help cope<br />
with emotional challenges, learning from others facing similar situations.<br />
Social skills groups for children teaches the kids how to interact appropriately with others their age<br />
having fun. (Children must be currently enrolled in our home/school based ABA programs for<br />
participation.</p>
<p>La entrada <a href="https://leadersabatherapy.com/service/child-and-caregiver-social-groups/">CHILD AND CAREGIVER SOCIAL GROUPS</a> se publicó primero en <a href="https://leadersabatherapy.com">Leaders Behavior ABA &amp; Counseling, LLC</a>.</p>
]]></description>
										<content:encoded><![CDATA[<div class="vc_row wpb_row vc_row-fluid"><div class="wpb_column vc_column_container vc_col-sm-6"><div class="vc_column-inner"><div class="wpb_wrapper">
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			<div class="vc_single_image-wrapper   vc_box_border_grey"><img fetchpriority="high" decoding="async" width="600" height="450" src="https://leadersabatherapy.com/wp-content/uploads/2021/01/csg-1.jpg" class="vc_single_image-img attachment-full" alt="" srcset="https://leadersabatherapy.com/wp-content/uploads/2021/01/csg-1.jpg 600w, https://leadersabatherapy.com/wp-content/uploads/2021/01/csg-1-300x225.jpg 300w" sizes="(max-width: 600px) 100vw, 600px" /></div>
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</div></div></div><div class="wpb_column vc_column_container vc_col-sm-6"><div class="vc_column-inner"><div class="wpb_wrapper"><h2 style="text-align: left" class="vc_custom_heading" >CHILD AND CAREGIVER SOCIAL GROUPS</h2>
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		<div class="wpb_wrapper">
			<p><span class="_Tgc _y9e">Building social group connections is a fantastic way for caregivers to learn parenting skills and help cope with emotional challenges, learning from others facing similar situations.<br />
Social skills groups for children teaches the kids how to interact appropriately with others their age while having fun. (Children must be currently enrolled in our home/school based ABA programs for participation)<br />
.</span></p>

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</div></div></div></div><div class="vc_row wpb_row vc_row-fluid"><div class="wpb_column vc_column_container vc_col-sm-12"><div class="vc_column-inner"><div class="wpb_wrapper"><div class="vc_empty_space"   style="height: 62px"><span class="vc_empty_space_inner"></span></div></div></div></div></div><div class="vc_row wpb_row vc_row-fluid"><div class="wpb_column vc_column_container vc_col-sm-12"><div class="vc_column-inner"><div class="wpb_wrapper"><h2 style="text-align: left;font-family:Abril Fatface;font-weight:400;font-style:normal" class="vc_custom_heading" >REQUEST SERVICE</h2><div  class="vc_wp_text wpb_content_element"><div class="widget widget_text">			<div class="textwidget"><style type="text/css">.super-form:not(.super-initialized) *:not(.super-load-icon) { visibility: hidden !important; }</style>
<div id="super-form-831" style="margin:0px 0px 0px 0px;" class="super-form super-form-831  super-default-rounded super-field-size-medium super-adaptive" data-hide="true" data-overlay="true" data-field-size="medium"><span class="super-load-icon"></span></p>
<form tabindex="0" autocomplete="on" enctype="multipart/form-data"><input type="hidden" name="sf_nonce" value="" /><input type="text" name="super_hp" size="25" value="" /></p>
<div class="super-shortcode super-field super-hidden"><input class="super-shortcode-field" type="hidden" value="831" name="hidden_form_id" /></div>
<div class="super-shortcode super-field super-heading   super-ungrouped  ">
<div class="super-heading-title">
<h1>Insurance Intake & Verification Form</h1>
</div>
<div class="super-heading-description" >
<div>Student/Caregiver Information</div>
</div>
</div>
<div style="padding-top:20px;padding-bottom:20px;" class="super-shortcode super-field super-divider  super-align-left  super-ungrouped   align-left border-single style-dashed back-0">
<div class="super-divider-inner" style="width:100%;border-color:#444444;border-top-width:1px;border-bottom-width:1px;height:1px;"></div>
</div>
<div class="super-shortcode super-field super-heading   super-ungrouped  ">
<div class="super-heading-title">
<h4>Student Name</h4>
</div>
</div>
<div class="super-grid super-shortcode">
<div class="super-shortcode super_one_half super-column grid-level-0 column-number-1 first-column ">
<div class="super-shortcode super-field super-text   super-ungrouped  ">
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="first_name" data-oname="first_name" data-validation="empty" data-email="First Name:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="First Name" data-placeholderFilled="First Name"><span>First Name</span></span></div>
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</div>
</div>
<div class="super-shortcode super_one_half super-column grid-level-0 column-number-2  ">
<div class="super-shortcode super-field super-text   super-ungrouped  ">
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="last_name" data-oname="last_name" data-validation="empty" data-email="Last Name:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Last Name" data-placeholderFilled="Last Name"><span>Last Name</span></span></div>
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</div>
</div>
</div>
<div class="super-shortcode super-field super-date super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Date of Birth</div>
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field super-datepicker" type="text" autocomplete="false"  value="" 
        name="date_b" 
        data-format="dd-mm-yy" 
        data-jsformat="dd-MM-yyyy" 
        data-connected-min="" 
        data-connected-min-days="1" 
        data-connected-max="" 
        data-connected-max-days="1" 
        data-range="-100:+5" 
        data-first-day="1"
        data-localization=""
        data-change-month="true"
        data-change-year="true"
        data-show-month-after-year=""
        data-show-week=""
        data-number-of-months="1"
        data-show-other-months=""
        data-select-other-months="false" data-work-days="true"data-weekends="true"data-maxPicks="1" data-oname="date_b" data-email="Date birth:" data-absolute-default="" data-default-value="" data-return_age="" readonly="true" /><span class="super-adaptive-placeholder" data-placeholder="Select a date" data-placeholderFilled="Select a date"><span>Select a date</span></span></div>
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</div>
<div class="super-shortcode super-field super-dropdown super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Gender</div>
<div class="super-field-wrapper "><input type="hidden" class="super-shortcode-field" name="Gender" value="" data-oname="Gender" data-email="Gender:" data-absolute-default="" data-default-value="" /><input tabindex="-1" type="text" name="super-dropdown-search" value="" data-logic="contains" /></p>
<ul class="super-dropdown-list">
<li data-value="" class="super-item super-placeholder">- select a option -</li>
<li class="super-item" data-value="male" data-search-value="Male">
<div>Male</div>
</li>
<li class="super-item" data-value="female" data-search-value="Female">
<div>Female</div>
</li>
<li class="super-item" data-value="non_binary" data-search-value="Non-binary">
<div>Non-binary</div>
</li>
</ul>
<p><span class="super-dropdown-arrow"><span class="super-after"><i class="fas fa-caret-down"></i></span></span><span class="super-adaptive-placeholder" data-placeholder="- select a option -" data-placeholderFilled="- select a option -"><span>- select a option -</span></span></div>
<div class="super-error-msg">¡Se requiere campo!</div>
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</div>
<div class="super-shortcode super-field super-heading   super-ungrouped  ">
<div class="super-heading-title">
<h4>Students address</h4>
</div>
</div>
<div class="super-shortcode super-field super-text   super-ungrouped  ">
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="address1" data-oname="address1" data-validation="empty" data-email="Address:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder=" Street Address " data-placeholderFilled="Address"><span> Street Address </span></span></div>
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</div>
<div class="super-shortcode super-field super-text   super-ungrouped  ">
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="address2" data-oname="address2" data-validation="empty" data-email="Address 2:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Street Address Line 2" data-placeholderFilled="Address"><span>Street Address Line 2</span></span></div>
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</div>
<div class="super-grid super-shortcode">
<div class="super-shortcode super_one_third super-column grid-level-0 column-number-1 first-column ">
<div class="super-shortcode super-field super-text   super-ungrouped  ">
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="zipcode" data-oname="zipcode" data-validation="empty" data-email="Zipcode:" data-absolute-default="" data-default-value="" data-minlength="4" /><span class="super-adaptive-placeholder" data-placeholder="Zipcode" data-placeholderFilled="Zipcode"><span>Zipcode</span></span></div>
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</div>
</div>
<div class="super-shortcode super_one_third super-column grid-level-0 column-number-2  ">
<div class="super-shortcode super-field super-text   super-ungrouped  ">
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="city" data-oname="city" data-validation="empty" data-email="City:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="City" data-placeholderFilled="City"><span>City</span></span></div>
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</div>
</div>
<div class="super-shortcode super_one_third super-column grid-level-0 column-number-3  ">
<div class="super-shortcode super-field super-dropdown   super-ungrouped  ">
<div class="super-field-wrapper "><input type="hidden" class="super-shortcode-field" name="state" value="" data-oname="state" data-email="State:" data-absolute-default="" data-default-value="" /><input tabindex="-1" type="text" name="super-dropdown-search" value="" data-logic="contains" /></p>
<ul class="super-dropdown-list">
<li data-value="" class="super-item super-placeholder">- select a state -</li>
<li class="super-item" data-value="AL" data-search-value="Alabama">
<div>Alabama</div>
</li>
<li class="super-item" data-value="AK" data-search-value="Alaska">
<div>Alaska</div>
</li>
<li class="super-item" data-value="AZ" data-search-value="Arizona">
<div>Arizona</div>
</li>
<li class="super-item" data-value="AR" data-search-value="Arkansas">
<div>Arkansas</div>
</li>
<li class="super-item" data-value="CA" data-search-value="California">
<div>California</div>
</li>
<li class="super-item" data-value="CO" data-search-value="Colorado">
<div>Colorado</div>
</li>
<li class="super-item" data-value="CT" data-search-value="Connecticut">
<div>Connecticut</div>
</li>
<li class="super-item" data-value="DE" data-search-value="Delaware">
<div>Delaware</div>
</li>
<li class="super-item" data-value="DC" data-search-value="District of Columbia">
<div>District of Columbia</div>
</li>
<li class="super-item" data-value="FL" data-search-value="Florida">
<div>Florida</div>
</li>
<li class="super-item" data-value="GA" data-search-value="Georgia">
<div>Georgia</div>
</li>
<li class="super-item" data-value="HI" data-search-value="Hawaii">
<div>Hawaii</div>
</li>
<li class="super-item" data-value="ID" data-search-value="Idaho">
<div>Idaho</div>
</li>
<li class="super-item" data-value="IL" data-search-value="Illinois">
<div>Illinois</div>
</li>
<li class="super-item" data-value="IN" data-search-value="Indiana">
<div>Indiana</div>
</li>
<li class="super-item" data-value="IA" data-search-value="Iowa">
<div>Iowa</div>
</li>
<li class="super-item" data-value="KS" data-search-value="Kansas">
<div>Kansas</div>
</li>
<li class="super-item" data-value="KY" data-search-value="Kentucky">
<div>Kentucky</div>
</li>
<li class="super-item" data-value="LA" data-search-value="Louisiana">
<div>Louisiana</div>
</li>
<li class="super-item" data-value="ME" data-search-value="Maine">
<div>Maine</div>
</li>
<li class="super-item" data-value="MD" data-search-value="Maryland">
<div>Maryland</div>
</li>
<li class="super-item" data-value="MA" data-search-value="Massachusetts">
<div>Massachusetts</div>
</li>
<li class="super-item" data-value="MI" data-search-value="Michigan">
<div>Michigan</div>
</li>
<li class="super-item" data-value="MN" data-search-value="Minnesota">
<div>Minnesota</div>
</li>
<li class="super-item" data-value="MS" data-search-value="Mississippi">
<div>Mississippi</div>
</li>
<li class="super-item" data-value="MO" data-search-value="Missouri">
<div>Missouri</div>
</li>
<li class="super-item" data-value="MT" data-search-value="Montana">
<div>Montana</div>
</li>
<li class="super-item" data-value="NE" data-search-value="Nebraska">
<div>Nebraska</div>
</li>
<li class="super-item" data-value="NV" data-search-value="Nevada">
<div>Nevada</div>
</li>
<li class="super-item" data-value="NH" data-search-value="New Hampshire">
<div>New Hampshire</div>
</li>
<li class="super-item" data-value="NJ" data-search-value="New Jersey">
<div>New Jersey</div>
</li>
<li class="super-item" data-value="NM" data-search-value="New Mexico">
<div>New Mexico</div>
</li>
<li class="super-item" data-value="NY" data-search-value="New York">
<div>New York</div>
</li>
<li class="super-item" data-value="NC" data-search-value="North Carolina">
<div>North Carolina</div>
</li>
<li class="super-item" data-value="ND" data-search-value="North Dakota">
<div>North Dakota</div>
</li>
<li class="super-item" data-value="OH" data-search-value="Ohio">
<div>Ohio</div>
</li>
<li class="super-item" data-value="OK" data-search-value="Oklahoma">
<div>Oklahoma</div>
</li>
<li class="super-item" data-value="OR" data-search-value="Oregon">
<div>Oregon</div>
</li>
<li class="super-item" data-value="PA" data-search-value="Pennsylvania">
<div>Pennsylvania</div>
</li>
<li class="super-item" data-value="RI" data-search-value="Rhode Island">
<div>Rhode Island</div>
</li>
<li class="super-item" data-value="SC" data-search-value="South Carolina">
<div>South Carolina</div>
</li>
<li class="super-item" data-value="SD" data-search-value="South Dakota">
<div>South Dakota</div>
</li>
<li class="super-item" data-value="TN" data-search-value="Tennessee">
<div>Tennessee</div>
</li>
<li class="super-item" data-value="TX" data-search-value="Texas">
<div>Texas</div>
</li>
<li class="super-item" data-value="UT" data-search-value="Utah">
<div>Utah</div>
</li>
<li class="super-item" data-value="VT" data-search-value="Vermont">
<div>Vermont</div>
</li>
<li class="super-item" data-value="VA" data-search-value="Virginia">
<div>Virginia</div>
</li>
<li class="super-item" data-value="WA" data-search-value="Washington">
<div>Washington</div>
</li>
<li class="super-item" data-value="WV" data-search-value="West Virginia">
<div>West Virginia</div>
</li>
<li class="super-item" data-value="WI" data-search-value="Wisconsin">
<div>Wisconsin</div>
</li>
<li class="super-item" data-value="WY" data-search-value="Wyoming">
<div>Wyoming</div>
</li>
</ul>
<p><span class="super-dropdown-arrow"><span class="super-after"><i class="fas fa-caret-down"></i></span></span><span class="super-adaptive-placeholder" data-placeholder="- select a state -" data-placeholderFilled="- select a state -"><span>- select a state -</span></span></div>
<div class="super-error-msg">¡Se requiere campo!</div>
<div class="super-empty-error-msg">¡Se requiere campo!</div>
</div>
</div>
</div>
<div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Does the student have a medical ASD diagnosis? </div>
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="ADS" data-oname="ADS" data-email="ADS:" data-absolute-default="" data-default-value="" /></div>
<div class="super-error-msg">¡Se requiere campo!</div>
<div class="super-empty-error-msg">¡Se requiere campo!</div>
</div>
<div class="super-shortcode super-field super-heading   super-ungrouped  ">
<div class="super-heading-title">
<h4>Responsible Caregiver Name</h4>
</div>
</div>
<div class="super-grid super-shortcode">
<div class="super-shortcode super_one_half super-column grid-level-0 column-number-1 first-column ">
<div class="super-shortcode super-field super-text   super-ungrouped  ">
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="first_namercn" data-oname="first_namercn" data-validation="empty" data-email="First Name RCN:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="First Name" data-placeholderFilled="First Name"><span>First Name</span></span></div>
<div class="super-error-msg">¡Se requiere campo!</div>
<div class="super-empty-error-msg">¡Se requiere campo!</div>
</div>
</div>
<div class="super-shortcode super_one_half super-column grid-level-0 column-number-2  ">
<div class="super-shortcode super-field super-text   super-ungrouped  ">
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="last_namercn" data-oname="last_namercn" data-validation="empty" data-email="Last Name rcn:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Last Name" data-placeholderFilled="Last Name"><span>Last Name</span></span></div>
<div class="super-error-msg">¡Se requiere campo!</div>
<div class="super-empty-error-msg">¡Se requiere campo!</div>
</div>
</div>
</div>
<div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Phone Number</div>
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="tel" name="phonenumber" data-oname="phonenumber" data-validation="phone" data-email="Phonenumber:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Phone Number " data-placeholderFilled="Phonenumber"><span>Phone Number </span></span></div>
<div class="super-error-msg">¡Se requiere campo!</div>
<div class="super-empty-error-msg">¡Se requiere campo!</div>
</div>
<div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">E-mail</div>
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="email" name="email" data-oname="email" data-validation="email" data-email="E-mail RCN:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="E-mail" data-placeholderFilled="E-mail Address"><span>E-mail</span></span></div>
<div class="super-error-msg">¡Se requiere campo!</div>
<div class="super-empty-error-msg">¡Se requiere campo!</div>
</div>
<div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Name of Prescribing Physician </div>
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="Name_of_Prescribing_Physician" data-oname="Name_of_Prescribing_Physician" data-email="Name of Prescribing Physician " data-absolute-default="" data-default-value="" /></div>
<div class="super-error-msg">¡Se requiere campo!</div>
<div class="super-empty-error-msg">¡Se requiere campo!</div>
</div>
<div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Dr. Phone number</div>
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="tel" name="phonenumber_dr" data-oname="phonenumber_dr" data-validation="phone" data-email="DrPhonenumber:" data-absolute-default="" data-default-value="" /></div>
<div class="super-error-msg">¡Se requiere campo!</div>
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</div>
<div class="super-shortcode super-field super-dropdown super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Hours available for ABA services (*10 hour minimum required):</div>
<div class="super-field-wrapper "><input type="hidden" class="super-shortcode-field" name="hours_aviable" value="" data-oname="hours_aviable" data-email="Hours available for ABA services (*10 hour minimum required):" data-absolute-default="" data-default-value="" /><input tabindex="-1" type="text" name="super-dropdown-search" value="" data-logic="contains" /></p>
<ul class="super-dropdown-list">
<li data-value="" class="super-item super-placeholder">- select an option -</li>
<li class="super-item" data-value="Morning " data-search-value="Morning ">
<div>Morning </div>
</li>
<li class="super-item" data-value="4PM-7PM" data-search-value="4PM-7PM">
<div>4PM-7PM</div>
</li>
<li class="super-item" data-value=" Weekend flexible" data-search-value=" Weekend flexible">
<div> Weekend flexible</div>
</li>
<li class="super-item" data-value="Afternoon (11-3)" data-search-value="Afternoon (11-3)">
<div>Afternoon (11-3)</div>
</li>
<li class="super-item" data-value="After 7PM" data-search-value="After 7PM">
<div>After 7PM</div>
</li>
<li class="super-item" data-value="Other" data-search-value="Other">
<div>Other</div>
</li>
</ul>
<p><span class="super-dropdown-arrow"><span class="super-after"><i class="fas fa-caret-down"></i></span></span><span class="super-adaptive-placeholder" data-placeholder="- select an option -" data-placeholderFilled="- select an option -"><span>- select an option -</span></span></div>
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</div>
<div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped   super-conditional-hidden" data-conditional-action="show" data-conditional-trigger="all">
<div class="super-label super-bottom-margin">Other</div>
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="otherHoursaviable" data-oname="otherHoursaviable" data-email="otherHoursaviable:" data-absolute-default="" data-default-value="" /></div>
<p><textarea class="super-conditional-logic" data-fields="{hours_aviable}">[{"field":"hours_aviable","logic":"equal","value":"Other","and_method":"","field_and":"","logic_and":"","value_and":""}]</textarea></p>
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</div>
<div class="super-shortcode super-field super-checkbox super-has-only-label   super-ungrouped   display-vertical">
<div class="super-label super-bottom-margin">Days Requesting Services (*4 days a week required)</div>
<div class="super-field-wrapper ">
<div class="super-items-list"><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value="monday" /></p>
<div>Monday</div>
<p></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value="Tuesday" /></p>
<div>Tuesday</div>
<p></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value="Wednesday" /></p>
<div>Wednesday</div>
<p></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value="Thursday" /></p>
<div>Thursday</div>
<p></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value=" Friday" /></p>
<div> Friday</div>
<p></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value="Saturday" /></p>
<div>Saturday</div>
<p></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value="Sunday" /></p>
<div>Sunday</div>
<p></label></div>
<p><input class="super-shortcode-field" type="hidden" name="days" value="" data-oname="days" data-validation="empty" data-email="Days Requesting Services (*4 days a week required):" data-absolute-default="" data-default-value="" data-admin-email-value="both" data-confirm-email-value="both" data-contact-entry-value="both" /></div>
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</div>
<div class="super-shortcode super-field super-radio super-has-only-label   super-ungrouped   display-vertical">
<div class="super-label super-bottom-margin">Referred by (allow us to thank them) </div>
<div class="super-field-wrapper ">
<div class="super-items-list"><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="Physician" /></p>
<div>Physician</div>
<p></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value=" Google/Internet Search" /></p>
<div> Google/Internet Search</div>
<p></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="Friend" /></p>
<div>Friend</div>
<p></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="Esti/ Intake Coordinator" /></p>
<div>Esti/ Intake Coordinator</div>
<p></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="other" /></p>
<div>Other</div>
<p></label></div>
<p><input class="super-shortcode-field" type="hidden" name="Referredfield" value="" data-oname="Referredfield" data-email="Referred by (allow us to thank them) :" data-absolute-default="" data-default-value="" /></div>
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</div>
<div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped   super-conditional-hidden" data-conditional-action="show" data-conditional-trigger="all">
<div class="super-label super-bottom-margin">Other</div>
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="otherreferred" data-oname="otherreferred" data-email="otherreferred" data-absolute-default="" data-default-value="" /></div>
<p><textarea class="super-conditional-logic" data-fields="{Referredfield}">[{"field":"{Referredfield}","logic":"equal","value":"other","and_method":"","field_and":"","logic_and":"","value_and":""}]</textarea></p>
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</div>
<div class="super-shortcode super-field super-textarea super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Additional Comments</div>
<div class="super-field-wrapper "><textarea tabindex="-1" class="super-shortcode-field" name="Additional_Comments" data-oname="Additional_Comments" data-email="Additional Comments:" data-absolute-default="" data-default-value="" ></textarea><span class="super-adaptive-placeholder" data-placeholder="Please provide us with any relevant information that may be important" data-placeholderFilled="Question"><span>Please provide us with any relevant information that may be important</span></span></div>
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</div>
<div style="padding-top:20px;padding-bottom:20px;" class="super-shortcode super-field super-divider  super-align-left  super-ungrouped   align-left border-single style-dashed back-0">
<div class="super-divider-inner" style="width:100%;border-color:#444444;border-top-width:1px;border-bottom-width:1px;height:1px;"></div>
</div>
<div class="super-shortcode super-field super-heading   super-ungrouped  ">
<div class="super-heading-title">
<h1>Parent(s)/Legal Guardian Information</h1>
</div>
</div>
<div class="super-shortcode super-field super-heading   super-ungrouped  ">
<div class="super-heading-title">
<h4>Caregiver Name</h4>
</div>
</div>
<div class="super-grid super-shortcode">
<div class="super-shortcode super_one_half super-column grid-level-0 column-number-1 first-column ">
<div class="super-shortcode super-field super-text   super-ungrouped  ">
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="first_namec" data-oname="first_namec" data-validation="empty" data-email="First Name C:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="First Name" data-placeholderFilled="First Name"><span>First Name</span></span></div>
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</div>
</div>
<div class="super-shortcode super_one_half super-column grid-level-0 column-number-2  ">
<div class="super-shortcode super-field super-text   super-ungrouped  ">
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="last_nameC" data-oname="last_nameC" data-validation="empty" data-email="Last Name C:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Last Name" data-placeholderFilled="Last Name"><span>Last Name</span></span></div>
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</div>
</div>
</div>
<div class="super-shortcode super-field super-text   super-ungrouped  ">
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="tel" name="phonenumber_c" data-oname="phonenumber_c" data-validation="phone" data-email="PhonenumbeCr:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Phone Number" data-placeholderFilled="Phonenumber"><span>Phone Number</span></span></div>
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</div>
<div class="super-shortcode super-field super-text   super-ungrouped  ">
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="email" name="email_c" data-oname="email_c" data-validation="email" data-email="Email addressC:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="E-mail Address" data-placeholderFilled="E-mail Address"><span>E-mail Address</span></span></div>
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</div>
<div style="padding-top:20px;padding-bottom:20px;" class="super-shortcode super-field super-divider  super-align-left  super-ungrouped   align-left border-single style-dashed back-0">
<div class="super-divider-inner" style="width:100%;border-color:#444444;border-top-width:1px;border-bottom-width:1px;height:1px;"></div>
</div>
<div class="super-shortcode super-field super-heading   super-ungrouped  ">
<div class="super-heading-title">
<h1>Insurance Information</h1>
</div>
</div>
<div style="padding-top:20px;padding-bottom:20px;" class="super-shortcode super-field super-divider  super-align-left  super-ungrouped   align-left border-single style-dashed back-0">
<div class="super-divider-inner" style="width:100%;border-color:#444444;border-top-width:1px;border-bottom-width:1px;height:1px;"></div>
</div>
<div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Primary Policyholder Name: </div>
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="Primary_Policyholder_Name" data-oname="Primary_Policyholder_Name" data-email="Primary Policyholder Name:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Primary Policyholder Name: " data-placeholderFilled="Name"><span>Primary Policyholder Name: </span></span></div>
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</div>
<div class="super-grid super-shortcode">
<div class="super-shortcode super_one_half super-column grid-level-0 column-number-1 first-column ">
<div class="super-shortcode super-field super-radio super-has-only-label   super-ungrouped   display-vertical">
<div class="super-label super-bottom-margin">Relationship to Student</div>
<div class="super-field-wrapper ">
<div class="super-items-list"><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="Mother" /></p>
<div>Mother</div>
<p></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="Father" /></p>
<div>Father</div>
<p></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="Self" /></p>
<div>Self</div>
<p></label></div>
<p><input class="super-shortcode-field" type="hidden" name="relation" value="" data-oname="relation" data-email="Relationship to Student:" data-absolute-default="" data-default-value="" /></div>
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</div>
</div>
<div class="super-shortcode super_one_half super-column grid-level-0 column-number-2  ">
<div class="super-shortcode super-field super-text   super-ungrouped  ">
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="otherrs" data-oname="otherrs" data-email="Relationship to Student Other:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Other" data-placeholderFilled="Name"><span>Other</span></span></div>
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</div>
</div>
</div>
<div class="super-shortcode super-field super-date super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Policyholder DOB</div>
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field super-datepicker" type="text" autocomplete="false"  value="" 
        name="Policyholder_DOB" 
        data-format="dd-mm-yy" 
        data-jsformat="dd-MM-yyyy" 
        data-connected-min="" 
        data-connected-min-days="1" 
        data-connected-max="" 
        data-connected-max-days="1" 
        data-range="-100:+5" 
        data-first-day="1"
        data-localization=""
        data-change-month="true"
        data-change-year="true"
        data-show-month-after-year=""
        data-show-week=""
        data-number-of-months="1"
        data-show-other-months=""
        data-select-other-months="false" data-work-days="true"data-weekends="true"data-maxPicks="1" data-oname="Policyholder_DOB" data-email="Policyholder DOB:" data-absolute-default="" data-default-value="" data-return_age="" readonly="true" /><span class="super-adaptive-placeholder" data-placeholder="Select a date" data-placeholderFilled="Select a date"><span>Select a date</span></span></div>
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</div>
<div class="super-shortcode super-field super-dropdown super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Primary Insurance Provider </div>
<div class="super-field-wrapper "><input type="hidden" class="super-shortcode-field" name="Primary_Insurance_Provider" value="" data-oname="Primary_Insurance_Provider" data-email="Primary Insurance Provider :" data-absolute-default="" data-default-value="" /><input tabindex="-1" type="text" name="super-dropdown-search" value="" data-logic="contains" /></p>
<ul class="super-dropdown-list">
<li data-value="" class="super-item super-placeholder">- select a option -</li>
<li class="super-item" data-value="UHC" data-search-value="UHC">
<div>UHC</div>
</li>
<li class="super-item" data-value="Aetna" data-search-value="Aetna">
<div>Aetna</div>
</li>
<li class="super-item" data-value="Child Heath Plus" data-search-value="Child Heath Plus">
<div>Child Heath Plus</div>
</li>
<li class="super-item" data-value="Cigna" data-search-value="Cigna">
<div>Cigna</div>
</li>
<li class="super-item" data-value="BCBS" data-search-value="BCBS">
<div>BCBS</div>
</li>
<li class="super-item" data-value="Oscar" data-search-value="Oscar">
<div>Oscar</div>
</li>
<li class="super-item" data-value="Emblem" data-search-value="Emblem">
<div>Emblem</div>
</li>
<li class="super-item" data-value="Empire SHIP NYS" data-search-value="Empire SHIP NYS">
<div>Empire SHIP NYS</div>
</li>
<li class="super-item" data-value="Fidelis Care" data-search-value="Fidelis Care">
<div>Fidelis Care</div>
</li>
<li class="super-item" data-value="GHI" data-search-value="GHI">
<div>GHI</div>
</li>
<li class="super-item" data-value="Horizon BCBS" data-search-value="Horizon BCBS">
<div>Horizon BCBS</div>
</li>
<li class="super-item" data-value="OPTUM" data-search-value="OPTUM">
<div>OPTUM</div>
</li>
<li class="super-item" data-value="Oxford" data-search-value="Oxford">
<div>Oxford</div>
</li>
<li class="super-item" data-value="United Behavioral Health" data-search-value="United Behavioral Health">
<div>United Behavioral Health</div>
</li>
<li class="super-item" data-value="Other" data-search-value="Other">
<div>Other</div>
</li>
</ul>
<p><span class="super-dropdown-arrow"><span class="super-after"><i class="fas fa-caret-down"></i></span></span><span class="super-adaptive-placeholder" data-placeholder="- select a option -" data-placeholderFilled="- select a option -"><span>- select a option -</span></span></div>
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</div>
<div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Insurance ID </div>
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="Insurance_ID" data-oname="Insurance_ID" data-email="Insurance ID:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Insurance ID " data-placeholderFilled="Name"><span>Insurance ID </span></span></div>
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</div>
<div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Group Number </div>
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="Group_Number" data-oname="Group_Number" data-email="Group Number :" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Group Number " data-placeholderFilled="Name"><span>Group Number </span></span></div>
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</div>
<div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Insurance Contact Number</div>
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="tel" name="Insurance_Contact_Number" data-oname="Insurance_Contact_Number" data-validation="phone" data-email="Insurance Contact Number:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Phone number" data-placeholderFilled="Phonenumber"><span>Phone number</span></span></div>
<div class="super-error-msg">¡Se requiere campo!</div>
<div class="super-empty-error-msg">¡Se requiere campo!</div>
</div>
<div class="super-shortcode super-field super-file super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Snap or upload photo of front of insurance card</div>
<div class="super-field-wrapper ">
<div class="super-fileupload-button"><i class="fas fa-plus"></i><span class="super-fileupload-button-text">Upload...</span></div>
<p><input tabindex="-1" class="super-shortcode-field super-fileupload" type="file" name="files[]"  data-file-size="5" data-upload-limit="5" data-accept-file-types="jpg|jpeg|png|gif|pdf|JPG|JPEG|PNG|GIF|PDF" /><input class="super-active-files" type="hidden" value="" name="Snap_or_upload_photo_of_front_of_insurance_card" data-oname="Snap_or_upload_photo_of_front_of_insurance_card" data-email="Snap or upload photo of front of insurance card:" data-absolute-default="" /></p>
<div class="super-progress-bar"></div>
<div class="super-fileupload-files"></div>
</div>
<div class="super-error-msg">¡Se requiere campo!</div>
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</div>
<div class="super-shortcode super-field super-file super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Snap or upload photo of back of insurance card</div>
<div class="super-field-wrapper ">
<div class="super-fileupload-button"><i class="fas fa-plus"></i><span class="super-fileupload-button-text">Upload...</span></div>
<p><input tabindex="-1" class="super-shortcode-field super-fileupload" type="file" name="files[]"  data-file-size="5" data-upload-limit="5" data-accept-file-types="jpg|jpeg|png|gif|pdf|JPG|JPEG|PNG|GIF|PDF" /><input class="super-active-files" type="hidden" value="" name="Snap_or_upload_photo_of_back_of_insurance_card" data-oname="Snap_or_upload_photo_of_back_of_insurance_card" data-email="Snap or upload photo of back of insurance card:" data-absolute-default="" /></p>
<div class="super-progress-bar"></div>
<div class="super-fileupload-files"></div>
</div>
<div class="super-error-msg">¡Se requiere campo!</div>
<div class="super-empty-error-msg">¡Se requiere campo!</div>
</div>
<div class="super-shortcode super-field super-textarea super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Consent Signature </div>
<div class="super-field-wrapper "><textarea tabindex="-1" class="super-shortcode-field" name="Consent_Signature_" data-oname="Consent_Signature_" data-email="Consent Signature :" data-absolute-default="" data-default-value="" ></textarea></div>
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</div>
<div data-color="#18288e" data-light="#2c3ca2" data-dark="#000a70" data-hover-color="#444444" data-hover-light="#585858" data-hover-dark="#262626" data-font="#ffffff" data-font-hover="#ffffff" data-radius="square" data-type="flat" class="super-extra-shortcode super-shortcode super-field super-button super-clear-none super-form-button super-radius-square super-type-flat super-button-medium super-button-align-left super-button-width-auto">
<div data-href="" class="super-button-wrap no_link">
<div class="super-button-name" data-action="submit" data-normal="Submit" data-loading="Loading...">Submit</div>
<p><span class="super-after"></span></div>
</div>
</form>
</div>
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</div>
		</div></div></div></div></div></div>
<p>La entrada <a href="https://leadersabatherapy.com/service/child-and-caregiver-social-groups/">CHILD AND CAREGIVER SOCIAL GROUPS</a> se publicó primero en <a href="https://leadersabatherapy.com">Leaders Behavior ABA &amp; Counseling, LLC</a>.</p>
]]></content:encoded>
					
		
		
			</item>
		<item>
		<title>ABA THERAPY  APPLIED BEHAVIOR ANALYSIS (ABA)</title>
		<link>https://leadersabatherapy.com/service/aba-therapy/</link>
		
		<dc:creator><![CDATA[admin]]></dc:creator>
		<pubDate>Wed, 05 Jul 2017 11:17:33 +0000</pubDate>
				<guid isPermaLink="false">http://capital.imithemes.com/demo1/?post_type=imi_services&#038;p=71</guid>

					<description><![CDATA[<p>ABA is an individualized and collaborative behavior treatment approach driven by assessment and data which includes many different techniques that are focused on antecedents (what precedes a certain behavior) and in consequences (what happens after a certain behavior). ABA therapy uses positive reinforcement in a way that can be measured in order to achieve a significant change in behavior.</p>
<p>La entrada <a href="https://leadersabatherapy.com/service/aba-therapy/">ABA THERAPY &lt;BR&gt; APPLIED BEHAVIOR ANALYSIS (ABA)</a> se publicó primero en <a href="https://leadersabatherapy.com">Leaders Behavior ABA &amp; Counseling, LLC</a>.</p>
]]></description>
										<content:encoded><![CDATA[<div class="vc_row wpb_row vc_row-fluid"><div class="wpb_column vc_column_container vc_col-sm-6"><div class="vc_column-inner"><div class="wpb_wrapper"><h2 style="text-align: left" class="vc_custom_heading" >APPLIED BEHAVIOR ANALYSIS (ABA)</h2>
	<div class="wpb_text_column wpb_content_element " >
		<div class="wpb_wrapper">
			<p>ABA is an individualized and collaborative behavior treatment approach driven by assessment and data which includes many different techniques that are focused on antecedents (what precedes a certain behavior) and in consequences (what happens after a certain behavior). ABA therapy uses positive reinforcement in a way that can be measured in order to achieve a significant change in behavior.</p>
<p>Typical goals of ABA therapy include functional communication, social skills development, independent and interactive play behavior, motor skills, tolerance, flexibility, daily living skills, reduction of problem behaviors, preparation for transition into school and is also implemented to increase attention, concentration, memory, and academic results.</p>
<p>Baer, Wolf &amp; Risley defined the science of applied behavior Analysis (ABA) best in 1968: “Applied Behavior Analysis is the process of systematically applying interventions based upon the principles of learning theory to improve socially significant behaviors to a meaningful degree, and to demonstrate that the interventions employed are responsible for the improvement in behavior”.</p>
<p>Director General of Health of the United States and the American Association of Psychology consider Applied Behavior Analysis (ABA) treatment  among the most recommended practices based on evidence. This means that ABA therapy has met scientific criteria of utility, quality and efficacy.</p>

		</div>
	</div>
</div></div></div><div class="wpb_column vc_column_container vc_col-sm-6"><div class="vc_column-inner"><div class="wpb_wrapper">
	<div  class="wpb_single_image wpb_content_element vc_align_left">
		
		<figure class="wpb_wrapper vc_figure">
			<div class="vc_single_image-wrapper   vc_box_border_grey"><img decoding="async" width="600" height="450" src="https://leadersabatherapy.com/wp-content/uploads/2021/01/aba-1.jpg" class="vc_single_image-img attachment-full" alt="" srcset="https://leadersabatherapy.com/wp-content/uploads/2021/01/aba-1.jpg 600w, https://leadersabatherapy.com/wp-content/uploads/2021/01/aba-1-300x225.jpg 300w" sizes="(max-width: 600px) 100vw, 600px" /></div>
		</figure>
	</div>
</div></div></div></div><div class="vc_row wpb_row vc_row-fluid"><div class="wpb_column vc_column_container vc_col-sm-12"><div class="vc_column-inner"><div class="wpb_wrapper"><h2 style="text-align: left" class="vc_custom_heading" >WE GUIDE YOU STEP BY STEP</h2><div class="vc_empty_space"   style="height: 20px"><span class="vc_empty_space_inner"></span></div><div class="vc_tta-container" data-vc-action="collapse"><div class="vc_general vc_tta vc_tta-accordion vc_tta-color-grey vc_tta-style-modern vc_tta-shape-rounded vc_tta-o-shape-group vc_tta-controls-align-left"><div class="vc_tta-panels-container"><div class="vc_tta-panels"><div class="vc_tta-panel vc_active" id="1499190539472-94034818-55938178-f85d" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title vc_tta-controls-icon-position-left"><a href="#1499190539472-94034818-55938178-f85d" data-vc-accordion data-vc-container=".vc_tta-container"><span class="vc_tta-title-text">STEP 1</span><i class="vc_tta-controls-icon vc_tta-controls-icon-triangle"></i></a></h4></div><div class="vc_tta-panel-body">
	<div class="wpb_text_column wpb_content_element " >
		<div class="wpb_wrapper">
			<p>We have enrollment forms available in the request session to gather important information such as diagnosis, insurance information and other important questions.</p>

		</div>
	</div>
</div></div><div class="vc_tta-panel" id="1499190578098-a52b500f-11708178-f85d" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title vc_tta-controls-icon-position-left"><a href="#1499190578098-a52b500f-11708178-f85d" data-vc-accordion data-vc-container=".vc_tta-container"><span class="vc_tta-title-text">STEP 2</span><i class="vc_tta-controls-icon vc_tta-controls-icon-triangle"></i></a></h4></div><div class="vc_tta-panel-body">
	<div class="wpb_text_column wpb_content_element " >
		<div class="wpb_wrapper">
			<p>A team member from Leaders Behavior ABA &amp; Counseling, LLC will contact you within 24/hours to begin insurance verification process, answer any additional questions and gather the necessary documents that include the client’s insurance card, a referral from your child’s doctor and a full diagnostic report to request an authorization for assessment from your insurance. Depending on your insurance it can take 1-2 weeks to receive the authorization.</p>

		</div>
	</div>
</div></div><div class="vc_tta-panel" id="1499190539587-62fb75d6-84268178-f85d" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title vc_tta-controls-icon-position-left"><a href="#1499190539587-62fb75d6-84268178-f85d" data-vc-accordion data-vc-container=".vc_tta-container"><span class="vc_tta-title-text">STEP 3</span><i class="vc_tta-controls-icon vc_tta-controls-icon-triangle"></i></a></h4></div><div class="vc_tta-panel-body">
	<div class="wpb_text_column wpb_content_element " >
		<div class="wpb_wrapper">
			<p>With authorization in hand, our BCBA’s will schedule with you several appointments to develop an interventive and customized treatment plan that your child deserves. It takes about 10 days to complete the report then the report is submitted to your insurance for an ongoing authorization that could takes 8-12 days.</p>

		</div>
	</div>
</div></div><div class="vc_tta-panel" id="1609810821226-7c208ca4-0764" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title vc_tta-controls-icon-position-left"><a href="#1609810821226-7c208ca4-0764" data-vc-accordion data-vc-container=".vc_tta-container"><span class="vc_tta-title-text">STEP 4</span><i class="vc_tta-controls-icon vc_tta-controls-icon-triangle"></i></a></h4></div><div class="vc_tta-panel-body">
	<div class="wpb_text_column wpb_content_element " >
		<div class="wpb_wrapper">
			<p>Begin our journey together to ensure the most emphatic care &amp; high quality service.</p>

		</div>
	</div>
</div></div></div></div></div></div><h2 style="text-align: left;font-family:Abril Fatface;font-weight:400;font-style:normal" class="vc_custom_heading" >REQUEST SERVICE</h2><div  class="vc_wp_text wpb_content_element"><div class="widget widget_text">			<div class="textwidget"><style type="text/css">.super-form:not(.super-initialized) *:not(.super-load-icon) { visibility: hidden !important; }</style>
<div id="super-form-831" style="margin:0px 0px 0px 0px;" class="super-form super-form-831  super-default-rounded super-field-size-medium super-adaptive" data-hide="true" data-overlay="true" data-field-size="medium"><span class="super-load-icon"></span></p>
<form tabindex="0" autocomplete="on" enctype="multipart/form-data"><input type="hidden" name="sf_nonce" value="" /><input type="text" name="super_hp" size="25" value="" /></p>
<div class="super-shortcode super-field super-hidden"><input class="super-shortcode-field" type="hidden" value="831" name="hidden_form_id" /></div>
<div class="super-shortcode super-field super-heading   super-ungrouped  ">
<div class="super-heading-title">
<h1>Insurance Intake & Verification Form</h1>
</div>
<div class="super-heading-description" >
<div>Student/Caregiver Information</div>
</div>
</div>
<div style="padding-top:20px;padding-bottom:20px;" class="super-shortcode super-field super-divider  super-align-left  super-ungrouped   align-left border-single style-dashed back-0">
<div class="super-divider-inner" style="width:100%;border-color:#444444;border-top-width:1px;border-bottom-width:1px;height:1px;"></div>
</div>
<div class="super-shortcode super-field super-heading   super-ungrouped  ">
<div class="super-heading-title">
<h4>Student Name</h4>
</div>
</div>
<div class="super-grid super-shortcode">
<div class="super-shortcode super_one_half super-column grid-level-0 column-number-1 first-column ">
<div class="super-shortcode super-field super-text   super-ungrouped  ">
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="first_name" data-oname="first_name" data-validation="empty" data-email="First Name:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="First Name" data-placeholderFilled="First Name"><span>First Name</span></span></div>
<div class="super-error-msg">¡Se requiere campo!</div>
<div class="super-empty-error-msg">¡Se requiere campo!</div>
</div>
</div>
<div class="super-shortcode super_one_half super-column grid-level-0 column-number-2  ">
<div class="super-shortcode super-field super-text   super-ungrouped  ">
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="last_name" data-oname="last_name" data-validation="empty" data-email="Last Name:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Last Name" data-placeholderFilled="Last Name"><span>Last Name</span></span></div>
<div class="super-error-msg">¡Se requiere campo!</div>
<div class="super-empty-error-msg">¡Se requiere campo!</div>
</div>
</div>
</div>
<div class="super-shortcode super-field super-date super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Date of Birth</div>
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field super-datepicker" type="text" autocomplete="false"  value="" 
        name="date_b" 
        data-format="dd-mm-yy" 
        data-jsformat="dd-MM-yyyy" 
        data-connected-min="" 
        data-connected-min-days="1" 
        data-connected-max="" 
        data-connected-max-days="1" 
        data-range="-100:+5" 
        data-first-day="1"
        data-localization=""
        data-change-month="true"
        data-change-year="true"
        data-show-month-after-year=""
        data-show-week=""
        data-number-of-months="1"
        data-show-other-months=""
        data-select-other-months="false" data-work-days="true"data-weekends="true"data-maxPicks="1" data-oname="date_b" data-email="Date birth:" data-absolute-default="" data-default-value="" data-return_age="" readonly="true" /><span class="super-adaptive-placeholder" data-placeholder="Select a date" data-placeholderFilled="Select a date"><span>Select a date</span></span></div>
<div class="super-error-msg">¡Se requiere campo!</div>
<div class="super-empty-error-msg">¡Se requiere campo!</div>
</div>
<div class="super-shortcode super-field super-dropdown super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Gender</div>
<div class="super-field-wrapper "><input type="hidden" class="super-shortcode-field" name="Gender" value="" data-oname="Gender" data-email="Gender:" data-absolute-default="" data-default-value="" /><input tabindex="-1" type="text" name="super-dropdown-search" value="" data-logic="contains" /></p>
<ul class="super-dropdown-list">
<li data-value="" class="super-item super-placeholder">- select a option -</li>
<li class="super-item" data-value="male" data-search-value="Male">
<div>Male</div>
</li>
<li class="super-item" data-value="female" data-search-value="Female">
<div>Female</div>
</li>
<li class="super-item" data-value="non_binary" data-search-value="Non-binary">
<div>Non-binary</div>
</li>
</ul>
<p><span class="super-dropdown-arrow"><span class="super-after"><i class="fas fa-caret-down"></i></span></span><span class="super-adaptive-placeholder" data-placeholder="- select a option -" data-placeholderFilled="- select a option -"><span>- select a option -</span></span></div>
<div class="super-error-msg">¡Se requiere campo!</div>
<div class="super-empty-error-msg">¡Se requiere campo!</div>
</div>
<div class="super-shortcode super-field super-heading   super-ungrouped  ">
<div class="super-heading-title">
<h4>Students address</h4>
</div>
</div>
<div class="super-shortcode super-field super-text   super-ungrouped  ">
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="address1" data-oname="address1" data-validation="empty" data-email="Address:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder=" Street Address " data-placeholderFilled="Address"><span> Street Address </span></span></div>
<div class="super-error-msg">¡Se requiere campo!</div>
<div class="super-empty-error-msg">¡Se requiere campo!</div>
</div>
<div class="super-shortcode super-field super-text   super-ungrouped  ">
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="address2" data-oname="address2" data-validation="empty" data-email="Address 2:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Street Address Line 2" data-placeholderFilled="Address"><span>Street Address Line 2</span></span></div>
<div class="super-error-msg">¡Se requiere campo!</div>
<div class="super-empty-error-msg">¡Se requiere campo!</div>
</div>
<div class="super-grid super-shortcode">
<div class="super-shortcode super_one_third super-column grid-level-0 column-number-1 first-column ">
<div class="super-shortcode super-field super-text   super-ungrouped  ">
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="zipcode" data-oname="zipcode" data-validation="empty" data-email="Zipcode:" data-absolute-default="" data-default-value="" data-minlength="4" /><span class="super-adaptive-placeholder" data-placeholder="Zipcode" data-placeholderFilled="Zipcode"><span>Zipcode</span></span></div>
<div class="super-error-msg">¡Se requiere campo!</div>
<div class="super-empty-error-msg">¡Se requiere campo!</div>
</div>
</div>
<div class="super-shortcode super_one_third super-column grid-level-0 column-number-2  ">
<div class="super-shortcode super-field super-text   super-ungrouped  ">
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="city" data-oname="city" data-validation="empty" data-email="City:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="City" data-placeholderFilled="City"><span>City</span></span></div>
<div class="super-error-msg">¡Se requiere campo!</div>
<div class="super-empty-error-msg">¡Se requiere campo!</div>
</div>
</div>
<div class="super-shortcode super_one_third super-column grid-level-0 column-number-3  ">
<div class="super-shortcode super-field super-dropdown   super-ungrouped  ">
<div class="super-field-wrapper "><input type="hidden" class="super-shortcode-field" name="state" value="" data-oname="state" data-email="State:" data-absolute-default="" data-default-value="" /><input tabindex="-1" type="text" name="super-dropdown-search" value="" data-logic="contains" /></p>
<ul class="super-dropdown-list">
<li data-value="" class="super-item super-placeholder">- select a state -</li>
<li class="super-item" data-value="AL" data-search-value="Alabama">
<div>Alabama</div>
</li>
<li class="super-item" data-value="AK" data-search-value="Alaska">
<div>Alaska</div>
</li>
<li class="super-item" data-value="AZ" data-search-value="Arizona">
<div>Arizona</div>
</li>
<li class="super-item" data-value="AR" data-search-value="Arkansas">
<div>Arkansas</div>
</li>
<li class="super-item" data-value="CA" data-search-value="California">
<div>California</div>
</li>
<li class="super-item" data-value="CO" data-search-value="Colorado">
<div>Colorado</div>
</li>
<li class="super-item" data-value="CT" data-search-value="Connecticut">
<div>Connecticut</div>
</li>
<li class="super-item" data-value="DE" data-search-value="Delaware">
<div>Delaware</div>
</li>
<li class="super-item" data-value="DC" data-search-value="District of Columbia">
<div>District of Columbia</div>
</li>
<li class="super-item" data-value="FL" data-search-value="Florida">
<div>Florida</div>
</li>
<li class="super-item" data-value="GA" data-search-value="Georgia">
<div>Georgia</div>
</li>
<li class="super-item" data-value="HI" data-search-value="Hawaii">
<div>Hawaii</div>
</li>
<li class="super-item" data-value="ID" data-search-value="Idaho">
<div>Idaho</div>
</li>
<li class="super-item" data-value="IL" data-search-value="Illinois">
<div>Illinois</div>
</li>
<li class="super-item" data-value="IN" data-search-value="Indiana">
<div>Indiana</div>
</li>
<li class="super-item" data-value="IA" data-search-value="Iowa">
<div>Iowa</div>
</li>
<li class="super-item" data-value="KS" data-search-value="Kansas">
<div>Kansas</div>
</li>
<li class="super-item" data-value="KY" data-search-value="Kentucky">
<div>Kentucky</div>
</li>
<li class="super-item" data-value="LA" data-search-value="Louisiana">
<div>Louisiana</div>
</li>
<li class="super-item" data-value="ME" data-search-value="Maine">
<div>Maine</div>
</li>
<li class="super-item" data-value="MD" data-search-value="Maryland">
<div>Maryland</div>
</li>
<li class="super-item" data-value="MA" data-search-value="Massachusetts">
<div>Massachusetts</div>
</li>
<li class="super-item" data-value="MI" data-search-value="Michigan">
<div>Michigan</div>
</li>
<li class="super-item" data-value="MN" data-search-value="Minnesota">
<div>Minnesota</div>
</li>
<li class="super-item" data-value="MS" data-search-value="Mississippi">
<div>Mississippi</div>
</li>
<li class="super-item" data-value="MO" data-search-value="Missouri">
<div>Missouri</div>
</li>
<li class="super-item" data-value="MT" data-search-value="Montana">
<div>Montana</div>
</li>
<li class="super-item" data-value="NE" data-search-value="Nebraska">
<div>Nebraska</div>
</li>
<li class="super-item" data-value="NV" data-search-value="Nevada">
<div>Nevada</div>
</li>
<li class="super-item" data-value="NH" data-search-value="New Hampshire">
<div>New Hampshire</div>
</li>
<li class="super-item" data-value="NJ" data-search-value="New Jersey">
<div>New Jersey</div>
</li>
<li class="super-item" data-value="NM" data-search-value="New Mexico">
<div>New Mexico</div>
</li>
<li class="super-item" data-value="NY" data-search-value="New York">
<div>New York</div>
</li>
<li class="super-item" data-value="NC" data-search-value="North Carolina">
<div>North Carolina</div>
</li>
<li class="super-item" data-value="ND" data-search-value="North Dakota">
<div>North Dakota</div>
</li>
<li class="super-item" data-value="OH" data-search-value="Ohio">
<div>Ohio</div>
</li>
<li class="super-item" data-value="OK" data-search-value="Oklahoma">
<div>Oklahoma</div>
</li>
<li class="super-item" data-value="OR" data-search-value="Oregon">
<div>Oregon</div>
</li>
<li class="super-item" data-value="PA" data-search-value="Pennsylvania">
<div>Pennsylvania</div>
</li>
<li class="super-item" data-value="RI" data-search-value="Rhode Island">
<div>Rhode Island</div>
</li>
<li class="super-item" data-value="SC" data-search-value="South Carolina">
<div>South Carolina</div>
</li>
<li class="super-item" data-value="SD" data-search-value="South Dakota">
<div>South Dakota</div>
</li>
<li class="super-item" data-value="TN" data-search-value="Tennessee">
<div>Tennessee</div>
</li>
<li class="super-item" data-value="TX" data-search-value="Texas">
<div>Texas</div>
</li>
<li class="super-item" data-value="UT" data-search-value="Utah">
<div>Utah</div>
</li>
<li class="super-item" data-value="VT" data-search-value="Vermont">
<div>Vermont</div>
</li>
<li class="super-item" data-value="VA" data-search-value="Virginia">
<div>Virginia</div>
</li>
<li class="super-item" data-value="WA" data-search-value="Washington">
<div>Washington</div>
</li>
<li class="super-item" data-value="WV" data-search-value="West Virginia">
<div>West Virginia</div>
</li>
<li class="super-item" data-value="WI" data-search-value="Wisconsin">
<div>Wisconsin</div>
</li>
<li class="super-item" data-value="WY" data-search-value="Wyoming">
<div>Wyoming</div>
</li>
</ul>
<p><span class="super-dropdown-arrow"><span class="super-after"><i class="fas fa-caret-down"></i></span></span><span class="super-adaptive-placeholder" data-placeholder="- select a state -" data-placeholderFilled="- select a state -"><span>- select a state -</span></span></div>
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</div>
</div>
<div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Does the student have a medical ASD diagnosis? </div>
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="ADS" data-oname="ADS" data-email="ADS:" data-absolute-default="" data-default-value="" /></div>
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</div>
<div class="super-shortcode super-field super-heading   super-ungrouped  ">
<div class="super-heading-title">
<h4>Responsible Caregiver Name</h4>
</div>
</div>
<div class="super-grid super-shortcode">
<div class="super-shortcode super_one_half super-column grid-level-0 column-number-1 first-column ">
<div class="super-shortcode super-field super-text   super-ungrouped  ">
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="first_namercn" data-oname="first_namercn" data-validation="empty" data-email="First Name RCN:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="First Name" data-placeholderFilled="First Name"><span>First Name</span></span></div>
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</div>
</div>
<div class="super-shortcode super_one_half super-column grid-level-0 column-number-2  ">
<div class="super-shortcode super-field super-text   super-ungrouped  ">
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="last_namercn" data-oname="last_namercn" data-validation="empty" data-email="Last Name rcn:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Last Name" data-placeholderFilled="Last Name"><span>Last Name</span></span></div>
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</div>
</div>
</div>
<div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Phone Number</div>
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="tel" name="phonenumber" data-oname="phonenumber" data-validation="phone" data-email="Phonenumber:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Phone Number " data-placeholderFilled="Phonenumber"><span>Phone Number </span></span></div>
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<div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">E-mail</div>
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="email" name="email" data-oname="email" data-validation="email" data-email="E-mail RCN:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="E-mail" data-placeholderFilled="E-mail Address"><span>E-mail</span></span></div>
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<div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Name of Prescribing Physician </div>
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="Name_of_Prescribing_Physician" data-oname="Name_of_Prescribing_Physician" data-email="Name of Prescribing Physician " data-absolute-default="" data-default-value="" /></div>
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<div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Dr. Phone number</div>
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="tel" name="phonenumber_dr" data-oname="phonenumber_dr" data-validation="phone" data-email="DrPhonenumber:" data-absolute-default="" data-default-value="" /></div>
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</div>
<div class="super-shortcode super-field super-dropdown super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Hours available for ABA services (*10 hour minimum required):</div>
<div class="super-field-wrapper "><input type="hidden" class="super-shortcode-field" name="hours_aviable" value="" data-oname="hours_aviable" data-email="Hours available for ABA services (*10 hour minimum required):" data-absolute-default="" data-default-value="" /><input tabindex="-1" type="text" name="super-dropdown-search" value="" data-logic="contains" /></p>
<ul class="super-dropdown-list">
<li data-value="" class="super-item super-placeholder">- select an option -</li>
<li class="super-item" data-value="Morning " data-search-value="Morning ">
<div>Morning </div>
</li>
<li class="super-item" data-value="4PM-7PM" data-search-value="4PM-7PM">
<div>4PM-7PM</div>
</li>
<li class="super-item" data-value=" Weekend flexible" data-search-value=" Weekend flexible">
<div> Weekend flexible</div>
</li>
<li class="super-item" data-value="Afternoon (11-3)" data-search-value="Afternoon (11-3)">
<div>Afternoon (11-3)</div>
</li>
<li class="super-item" data-value="After 7PM" data-search-value="After 7PM">
<div>After 7PM</div>
</li>
<li class="super-item" data-value="Other" data-search-value="Other">
<div>Other</div>
</li>
</ul>
<p><span class="super-dropdown-arrow"><span class="super-after"><i class="fas fa-caret-down"></i></span></span><span class="super-adaptive-placeholder" data-placeholder="- select an option -" data-placeholderFilled="- select an option -"><span>- select an option -</span></span></div>
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</div>
<div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped   super-conditional-hidden" data-conditional-action="show" data-conditional-trigger="all">
<div class="super-label super-bottom-margin">Other</div>
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="otherHoursaviable" data-oname="otherHoursaviable" data-email="otherHoursaviable:" data-absolute-default="" data-default-value="" /></div>
<p><textarea class="super-conditional-logic" data-fields="{hours_aviable}">[{"field":"hours_aviable","logic":"equal","value":"Other","and_method":"","field_and":"","logic_and":"","value_and":""}]</textarea></p>
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</div>
<div class="super-shortcode super-field super-checkbox super-has-only-label   super-ungrouped   display-vertical">
<div class="super-label super-bottom-margin">Days Requesting Services (*4 days a week required)</div>
<div class="super-field-wrapper ">
<div class="super-items-list"><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value="monday" /></p>
<div>Monday</div>
<p></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value="Tuesday" /></p>
<div>Tuesday</div>
<p></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value="Wednesday" /></p>
<div>Wednesday</div>
<p></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value="Thursday" /></p>
<div>Thursday</div>
<p></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value=" Friday" /></p>
<div> Friday</div>
<p></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value="Saturday" /></p>
<div>Saturday</div>
<p></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value="Sunday" /></p>
<div>Sunday</div>
<p></label></div>
<p><input class="super-shortcode-field" type="hidden" name="days" value="" data-oname="days" data-validation="empty" data-email="Days Requesting Services (*4 days a week required):" data-absolute-default="" data-default-value="" data-admin-email-value="both" data-confirm-email-value="both" data-contact-entry-value="both" /></div>
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<div class="super-shortcode super-field super-radio super-has-only-label   super-ungrouped   display-vertical">
<div class="super-label super-bottom-margin">Referred by (allow us to thank them) </div>
<div class="super-field-wrapper ">
<div class="super-items-list"><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="Physician" /></p>
<div>Physician</div>
<p></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value=" Google/Internet Search" /></p>
<div> Google/Internet Search</div>
<p></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="Friend" /></p>
<div>Friend</div>
<p></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="Esti/ Intake Coordinator" /></p>
<div>Esti/ Intake Coordinator</div>
<p></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="other" /></p>
<div>Other</div>
<p></label></div>
<p><input class="super-shortcode-field" type="hidden" name="Referredfield" value="" data-oname="Referredfield" data-email="Referred by (allow us to thank them) :" data-absolute-default="" data-default-value="" /></div>
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</div>
<div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped   super-conditional-hidden" data-conditional-action="show" data-conditional-trigger="all">
<div class="super-label super-bottom-margin">Other</div>
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="otherreferred" data-oname="otherreferred" data-email="otherreferred" data-absolute-default="" data-default-value="" /></div>
<p><textarea class="super-conditional-logic" data-fields="{Referredfield}">[{"field":"{Referredfield}","logic":"equal","value":"other","and_method":"","field_and":"","logic_and":"","value_and":""}]</textarea></p>
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</div>
<div class="super-shortcode super-field super-textarea super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Additional Comments</div>
<div class="super-field-wrapper "><textarea tabindex="-1" class="super-shortcode-field" name="Additional_Comments" data-oname="Additional_Comments" data-email="Additional Comments:" data-absolute-default="" data-default-value="" ></textarea><span class="super-adaptive-placeholder" data-placeholder="Please provide us with any relevant information that may be important" data-placeholderFilled="Question"><span>Please provide us with any relevant information that may be important</span></span></div>
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</div>
<div style="padding-top:20px;padding-bottom:20px;" class="super-shortcode super-field super-divider  super-align-left  super-ungrouped   align-left border-single style-dashed back-0">
<div class="super-divider-inner" style="width:100%;border-color:#444444;border-top-width:1px;border-bottom-width:1px;height:1px;"></div>
</div>
<div class="super-shortcode super-field super-heading   super-ungrouped  ">
<div class="super-heading-title">
<h1>Parent(s)/Legal Guardian Information</h1>
</div>
</div>
<div class="super-shortcode super-field super-heading   super-ungrouped  ">
<div class="super-heading-title">
<h4>Caregiver Name</h4>
</div>
</div>
<div class="super-grid super-shortcode">
<div class="super-shortcode super_one_half super-column grid-level-0 column-number-1 first-column ">
<div class="super-shortcode super-field super-text   super-ungrouped  ">
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="first_namec" data-oname="first_namec" data-validation="empty" data-email="First Name C:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="First Name" data-placeholderFilled="First Name"><span>First Name</span></span></div>
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</div>
</div>
<div class="super-shortcode super_one_half super-column grid-level-0 column-number-2  ">
<div class="super-shortcode super-field super-text   super-ungrouped  ">
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="last_nameC" data-oname="last_nameC" data-validation="empty" data-email="Last Name C:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Last Name" data-placeholderFilled="Last Name"><span>Last Name</span></span></div>
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</div>
</div>
</div>
<div class="super-shortcode super-field super-text   super-ungrouped  ">
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="tel" name="phonenumber_c" data-oname="phonenumber_c" data-validation="phone" data-email="PhonenumbeCr:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Phone Number" data-placeholderFilled="Phonenumber"><span>Phone Number</span></span></div>
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</div>
<div class="super-shortcode super-field super-text   super-ungrouped  ">
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="email" name="email_c" data-oname="email_c" data-validation="email" data-email="Email addressC:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="E-mail Address" data-placeholderFilled="E-mail Address"><span>E-mail Address</span></span></div>
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</div>
<div style="padding-top:20px;padding-bottom:20px;" class="super-shortcode super-field super-divider  super-align-left  super-ungrouped   align-left border-single style-dashed back-0">
<div class="super-divider-inner" style="width:100%;border-color:#444444;border-top-width:1px;border-bottom-width:1px;height:1px;"></div>
</div>
<div class="super-shortcode super-field super-heading   super-ungrouped  ">
<div class="super-heading-title">
<h1>Insurance Information</h1>
</div>
</div>
<div style="padding-top:20px;padding-bottom:20px;" class="super-shortcode super-field super-divider  super-align-left  super-ungrouped   align-left border-single style-dashed back-0">
<div class="super-divider-inner" style="width:100%;border-color:#444444;border-top-width:1px;border-bottom-width:1px;height:1px;"></div>
</div>
<div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Primary Policyholder Name: </div>
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="Primary_Policyholder_Name" data-oname="Primary_Policyholder_Name" data-email="Primary Policyholder Name:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Primary Policyholder Name: " data-placeholderFilled="Name"><span>Primary Policyholder Name: </span></span></div>
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</div>
<div class="super-grid super-shortcode">
<div class="super-shortcode super_one_half super-column grid-level-0 column-number-1 first-column ">
<div class="super-shortcode super-field super-radio super-has-only-label   super-ungrouped   display-vertical">
<div class="super-label super-bottom-margin">Relationship to Student</div>
<div class="super-field-wrapper ">
<div class="super-items-list"><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="Mother" /></p>
<div>Mother</div>
<p></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="Father" /></p>
<div>Father</div>
<p></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="Self" /></p>
<div>Self</div>
<p></label></div>
<p><input class="super-shortcode-field" type="hidden" name="relation" value="" data-oname="relation" data-email="Relationship to Student:" data-absolute-default="" data-default-value="" /></div>
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</div>
</div>
<div class="super-shortcode super_one_half super-column grid-level-0 column-number-2  ">
<div class="super-shortcode super-field super-text   super-ungrouped  ">
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="otherrs" data-oname="otherrs" data-email="Relationship to Student Other:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Other" data-placeholderFilled="Name"><span>Other</span></span></div>
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</div>
</div>
</div>
<div class="super-shortcode super-field super-date super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Policyholder DOB</div>
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field super-datepicker" type="text" autocomplete="false"  value="" 
        name="Policyholder_DOB" 
        data-format="dd-mm-yy" 
        data-jsformat="dd-MM-yyyy" 
        data-connected-min="" 
        data-connected-min-days="1" 
        data-connected-max="" 
        data-connected-max-days="1" 
        data-range="-100:+5" 
        data-first-day="1"
        data-localization=""
        data-change-month="true"
        data-change-year="true"
        data-show-month-after-year=""
        data-show-week=""
        data-number-of-months="1"
        data-show-other-months=""
        data-select-other-months="false" data-work-days="true"data-weekends="true"data-maxPicks="1" data-oname="Policyholder_DOB" data-email="Policyholder DOB:" data-absolute-default="" data-default-value="" data-return_age="" readonly="true" /><span class="super-adaptive-placeholder" data-placeholder="Select a date" data-placeholderFilled="Select a date"><span>Select a date</span></span></div>
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</div>
<div class="super-shortcode super-field super-dropdown super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Primary Insurance Provider </div>
<div class="super-field-wrapper "><input type="hidden" class="super-shortcode-field" name="Primary_Insurance_Provider" value="" data-oname="Primary_Insurance_Provider" data-email="Primary Insurance Provider :" data-absolute-default="" data-default-value="" /><input tabindex="-1" type="text" name="super-dropdown-search" value="" data-logic="contains" /></p>
<ul class="super-dropdown-list">
<li data-value="" class="super-item super-placeholder">- select a option -</li>
<li class="super-item" data-value="UHC" data-search-value="UHC">
<div>UHC</div>
</li>
<li class="super-item" data-value="Aetna" data-search-value="Aetna">
<div>Aetna</div>
</li>
<li class="super-item" data-value="Child Heath Plus" data-search-value="Child Heath Plus">
<div>Child Heath Plus</div>
</li>
<li class="super-item" data-value="Cigna" data-search-value="Cigna">
<div>Cigna</div>
</li>
<li class="super-item" data-value="BCBS" data-search-value="BCBS">
<div>BCBS</div>
</li>
<li class="super-item" data-value="Oscar" data-search-value="Oscar">
<div>Oscar</div>
</li>
<li class="super-item" data-value="Emblem" data-search-value="Emblem">
<div>Emblem</div>
</li>
<li class="super-item" data-value="Empire SHIP NYS" data-search-value="Empire SHIP NYS">
<div>Empire SHIP NYS</div>
</li>
<li class="super-item" data-value="Fidelis Care" data-search-value="Fidelis Care">
<div>Fidelis Care</div>
</li>
<li class="super-item" data-value="GHI" data-search-value="GHI">
<div>GHI</div>
</li>
<li class="super-item" data-value="Horizon BCBS" data-search-value="Horizon BCBS">
<div>Horizon BCBS</div>
</li>
<li class="super-item" data-value="OPTUM" data-search-value="OPTUM">
<div>OPTUM</div>
</li>
<li class="super-item" data-value="Oxford" data-search-value="Oxford">
<div>Oxford</div>
</li>
<li class="super-item" data-value="United Behavioral Health" data-search-value="United Behavioral Health">
<div>United Behavioral Health</div>
</li>
<li class="super-item" data-value="Other" data-search-value="Other">
<div>Other</div>
</li>
</ul>
<p><span class="super-dropdown-arrow"><span class="super-after"><i class="fas fa-caret-down"></i></span></span><span class="super-adaptive-placeholder" data-placeholder="- select a option -" data-placeholderFilled="- select a option -"><span>- select a option -</span></span></div>
<div class="super-error-msg">¡Se requiere campo!</div>
<div class="super-empty-error-msg">¡Se requiere campo!</div>
</div>
<div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Insurance ID </div>
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="Insurance_ID" data-oname="Insurance_ID" data-email="Insurance ID:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Insurance ID " data-placeholderFilled="Name"><span>Insurance ID </span></span></div>
<div class="super-error-msg">¡Se requiere campo!</div>
<div class="super-empty-error-msg">¡Se requiere campo!</div>
</div>
<div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Group Number </div>
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="Group_Number" data-oname="Group_Number" data-email="Group Number :" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Group Number " data-placeholderFilled="Name"><span>Group Number </span></span></div>
<div class="super-error-msg">¡Se requiere campo!</div>
<div class="super-empty-error-msg">¡Se requiere campo!</div>
</div>
<div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Insurance Contact Number</div>
<div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="tel" name="Insurance_Contact_Number" data-oname="Insurance_Contact_Number" data-validation="phone" data-email="Insurance Contact Number:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Phone number" data-placeholderFilled="Phonenumber"><span>Phone number</span></span></div>
<div class="super-error-msg">¡Se requiere campo!</div>
<div class="super-empty-error-msg">¡Se requiere campo!</div>
</div>
<div class="super-shortcode super-field super-file super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Snap or upload photo of front of insurance card</div>
<div class="super-field-wrapper ">
<div class="super-fileupload-button"><i class="fas fa-plus"></i><span class="super-fileupload-button-text">Upload...</span></div>
<p><input tabindex="-1" class="super-shortcode-field super-fileupload" type="file" name="files[]"  data-file-size="5" data-upload-limit="5" data-accept-file-types="jpg|jpeg|png|gif|pdf|JPG|JPEG|PNG|GIF|PDF" /><input class="super-active-files" type="hidden" value="" name="Snap_or_upload_photo_of_front_of_insurance_card" data-oname="Snap_or_upload_photo_of_front_of_insurance_card" data-email="Snap or upload photo of front of insurance card:" data-absolute-default="" /></p>
<div class="super-progress-bar"></div>
<div class="super-fileupload-files"></div>
</div>
<div class="super-error-msg">¡Se requiere campo!</div>
<div class="super-empty-error-msg">¡Se requiere campo!</div>
</div>
<div class="super-shortcode super-field super-file super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Snap or upload photo of back of insurance card</div>
<div class="super-field-wrapper ">
<div class="super-fileupload-button"><i class="fas fa-plus"></i><span class="super-fileupload-button-text">Upload...</span></div>
<p><input tabindex="-1" class="super-shortcode-field super-fileupload" type="file" name="files[]"  data-file-size="5" data-upload-limit="5" data-accept-file-types="jpg|jpeg|png|gif|pdf|JPG|JPEG|PNG|GIF|PDF" /><input class="super-active-files" type="hidden" value="" name="Snap_or_upload_photo_of_back_of_insurance_card" data-oname="Snap_or_upload_photo_of_back_of_insurance_card" data-email="Snap or upload photo of back of insurance card:" data-absolute-default="" /></p>
<div class="super-progress-bar"></div>
<div class="super-fileupload-files"></div>
</div>
<div class="super-error-msg">¡Se requiere campo!</div>
<div class="super-empty-error-msg">¡Se requiere campo!</div>
</div>
<div class="super-shortcode super-field super-textarea super-has-only-label   super-ungrouped  ">
<div class="super-label super-bottom-margin">Consent Signature </div>
<div class="super-field-wrapper "><textarea tabindex="-1" class="super-shortcode-field" name="Consent_Signature_" data-oname="Consent_Signature_" data-email="Consent Signature :" data-absolute-default="" data-default-value="" ></textarea></div>
<div class="super-error-msg">¡Se requiere campo!</div>
<div class="super-empty-error-msg">¡Se requiere campo!</div>
</div>
<div data-color="#18288e" data-light="#2c3ca2" data-dark="#000a70" data-hover-color="#444444" data-hover-light="#585858" data-hover-dark="#262626" data-font="#ffffff" data-font-hover="#ffffff" data-radius="square" data-type="flat" class="super-extra-shortcode super-shortcode super-field super-button super-clear-none super-form-button super-radius-square super-type-flat super-button-medium super-button-align-left super-button-width-auto">
<div data-href="" class="super-button-wrap no_link">
<div class="super-button-name" data-action="submit" data-normal="Submit" data-loading="Loading...">Submit</div>
<p><span class="super-after"></span></div>
</div>
</form>
</div>
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<p>La entrada <a href="https://leadersabatherapy.com/service/aba-therapy/">ABA THERAPY &lt;BR&gt; APPLIED BEHAVIOR ANALYSIS (ABA)</a> se publicó primero en <a href="https://leadersabatherapy.com">Leaders Behavior ABA &amp; Counseling, LLC</a>.</p>
]]></content:encoded>
					
		
		
			</item>
		<item>
		<title>COUNSELING</title>
		<link>https://leadersabatherapy.com/service/counseling/</link>
		
		<dc:creator><![CDATA[admin]]></dc:creator>
		<pubDate>Wed, 05 Jul 2017 10:47:05 +0000</pubDate>
				<guid isPermaLink="false">http://capital.imithemes.com/demo1/?post_type=imi_services&#038;p=69</guid>

					<description><![CDATA[<p>According to the American Counseling Association, counseling is defined as, "a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals."</p>
<p>La entrada <a href="https://leadersabatherapy.com/service/counseling/">COUNSELING</a> se publicó primero en <a href="https://leadersabatherapy.com">Leaders Behavior ABA &amp; Counseling, LLC</a>.</p>
]]></description>
										<content:encoded><![CDATA[<div class="vc_row wpb_row vc_row-fluid"><div class="wpb_column vc_column_container vc_col-sm-12"><div class="vc_column-inner"><div class="wpb_wrapper"></div></div></div></div><div class="vc_row wpb_row vc_row-fluid"><div class="wpb_column vc_column_container vc_col-sm-6"><div class="vc_column-inner"><div class="wpb_wrapper"><h2 style="text-align: left" class="vc_custom_heading" >COUNSELING</h2>
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			<p>According to the American Counseling Association, counseling is defined as, «a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals.» Counseling involves helping people make needed changes in ways of thinking, feeling, and behaving, and is a goal-based collaborative process, involving a non-judgmental, supportive and compassionate counselor who works with a client setting viable goals, developing strategies and plans necessary to accomplish these goals.</p>

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			<div class="vc_single_image-wrapper   vc_box_border_grey"><img decoding="async" width="600" height="450" src="https://leadersabatherapy.com/wp-content/uploads/2021/01/couseling-1.jpg" class="vc_single_image-img attachment-full" alt="" srcset="https://leadersabatherapy.com/wp-content/uploads/2021/01/couseling-1.jpg 600w, https://leadersabatherapy.com/wp-content/uploads/2021/01/couseling-1-300x225.jpg 300w" sizes="(max-width: 600px) 100vw, 600px" /></div>
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</div></div></div></div><div class="vc_row wpb_row vc_row-fluid"><div class="wpb_column vc_column_container vc_col-sm-12"><div class="vc_column-inner"><div class="wpb_wrapper"><div class="vc_empty_space"   style="height: 32px"><span class="vc_empty_space_inner"></span></div><h2 style="text-align: left;font-family:Abril Fatface;font-weight:400;font-style:normal" class="vc_custom_heading" >REQUEST SERVICE</h2>
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class="super-item super-placeholder">- select a option -</li><li class="super-item" data-value="male" data-search-value="Male"><div>Male</div></li><li class="super-item" data-value="female" data-search-value="Female"><div>Female</div></li><li class="super-item" data-value="non_binary" data-search-value="Non-binary"><div>Non-binary</div></li></ul><span class="super-dropdown-arrow"><span class="super-after"><i class="fas fa-caret-down"></i></span></span><span class="super-adaptive-placeholder" data-placeholder="- select a option -" data-placeholderFilled="- select a option -"><span>- select a option -</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-heading   super-ungrouped  "><div class="super-heading-title"><h4>Students address</h4></div></div><div class="super-shortcode super-field super-text   super-ungrouped  "><div class="super-field-wrapper 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class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-grid super-shortcode"><div class="super-shortcode super_one_third super-column grid-level-0 column-number-1 first-column "><div class="super-shortcode super-field super-text   super-ungrouped  "><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="zipcode" data-oname="zipcode" data-validation="empty" data-email="Zipcode:" data-absolute-default="" data-default-value="" data-minlength="4" /><span class="super-adaptive-placeholder" data-placeholder="Zipcode" data-placeholderFilled="Zipcode"><span>Zipcode</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div></div><div class="super-shortcode super_one_third super-column grid-level-0 column-number-2  "><div class="super-shortcode super-field super-text   super-ungrouped  "><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="city" data-oname="city" data-validation="empty" data-email="City:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="City" data-placeholderFilled="City"><span>City</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div></div><div class="super-shortcode super_one_third super-column grid-level-0 column-number-3  "><div class="super-shortcode super-field super-dropdown   super-ungrouped  "><div class="super-field-wrapper "><input type="hidden" class="super-shortcode-field" name="state" value="" data-oname="state" data-email="State:" data-absolute-default="" data-default-value="" /><input tabindex="-1" type="text" name="super-dropdown-search" value="" data-logic="contains" /><ul class="super-dropdown-list"><li data-value="" class="super-item super-placeholder">- select a state -</li><li class="super-item" data-value="AL" data-search-value="Alabama"><div>Alabama</div></li><li class="super-item" data-value="AK" data-search-value="Alaska"><div>Alaska</div></li><li class="super-item" data-value="AZ" data-search-value="Arizona"><div>Arizona</div></li><li class="super-item" data-value="AR" data-search-value="Arkansas"><div>Arkansas</div></li><li class="super-item" data-value="CA" data-search-value="California"><div>California</div></li><li class="super-item" data-value="CO" data-search-value="Colorado"><div>Colorado</div></li><li class="super-item" data-value="CT" data-search-value="Connecticut"><div>Connecticut</div></li><li class="super-item" data-value="DE" data-search-value="Delaware"><div>Delaware</div></li><li class="super-item" data-value="DC" data-search-value="District of Columbia"><div>District of Columbia</div></li><li class="super-item" data-value="FL" data-search-value="Florida"><div>Florida</div></li><li class="super-item" data-value="GA" data-search-value="Georgia"><div>Georgia</div></li><li class="super-item" data-value="HI" data-search-value="Hawaii"><div>Hawaii</div></li><li class="super-item" data-value="ID" data-search-value="Idaho"><div>Idaho</div></li><li class="super-item" data-value="IL" data-search-value="Illinois"><div>Illinois</div></li><li class="super-item" data-value="IN" data-search-value="Indiana"><div>Indiana</div></li><li class="super-item" data-value="IA" data-search-value="Iowa"><div>Iowa</div></li><li class="super-item" data-value="KS" data-search-value="Kansas"><div>Kansas</div></li><li class="super-item" data-value="KY" data-search-value="Kentucky"><div>Kentucky</div></li><li class="super-item" data-value="LA" data-search-value="Louisiana"><div>Louisiana</div></li><li class="super-item" data-value="ME" data-search-value="Maine"><div>Maine</div></li><li class="super-item" data-value="MD" data-search-value="Maryland"><div>Maryland</div></li><li class="super-item" data-value="MA" data-search-value="Massachusetts"><div>Massachusetts</div></li><li class="super-item" data-value="MI" data-search-value="Michigan"><div>Michigan</div></li><li class="super-item" data-value="MN" data-search-value="Minnesota"><div>Minnesota</div></li><li class="super-item" data-value="MS" data-search-value="Mississippi"><div>Mississippi</div></li><li class="super-item" data-value="MO" data-search-value="Missouri"><div>Missouri</div></li><li class="super-item" data-value="MT" data-search-value="Montana"><div>Montana</div></li><li class="super-item" data-value="NE" data-search-value="Nebraska"><div>Nebraska</div></li><li class="super-item" data-value="NV" data-search-value="Nevada"><div>Nevada</div></li><li class="super-item" data-value="NH" data-search-value="New Hampshire"><div>New Hampshire</div></li><li class="super-item" data-value="NJ" data-search-value="New Jersey"><div>New Jersey</div></li><li class="super-item" data-value="NM" data-search-value="New Mexico"><div>New Mexico</div></li><li class="super-item" data-value="NY" data-search-value="New York"><div>New York</div></li><li class="super-item" data-value="NC" data-search-value="North Carolina"><div>North Carolina</div></li><li class="super-item" data-value="ND" data-search-value="North Dakota"><div>North Dakota</div></li><li class="super-item" data-value="OH" data-search-value="Ohio"><div>Ohio</div></li><li class="super-item" data-value="OK" data-search-value="Oklahoma"><div>Oklahoma</div></li><li class="super-item" data-value="OR" data-search-value="Oregon"><div>Oregon</div></li><li class="super-item" data-value="PA" data-search-value="Pennsylvania"><div>Pennsylvania</div></li><li class="super-item" data-value="RI" data-search-value="Rhode Island"><div>Rhode Island</div></li><li class="super-item" data-value="SC" data-search-value="South Carolina"><div>South Carolina</div></li><li class="super-item" data-value="SD" data-search-value="South Dakota"><div>South Dakota</div></li><li class="super-item" data-value="TN" data-search-value="Tennessee"><div>Tennessee</div></li><li class="super-item" data-value="TX" data-search-value="Texas"><div>Texas</div></li><li class="super-item" data-value="UT" data-search-value="Utah"><div>Utah</div></li><li class="super-item" data-value="VT" data-search-value="Vermont"><div>Vermont</div></li><li class="super-item" data-value="VA" data-search-value="Virginia"><div>Virginia</div></li><li class="super-item" data-value="WA" data-search-value="Washington"><div>Washington</div></li><li class="super-item" data-value="WV" data-search-value="West Virginia"><div>West Virginia</div></li><li class="super-item" data-value="WI" data-search-value="Wisconsin"><div>Wisconsin</div></li><li class="super-item" data-value="WY" data-search-value="Wyoming"><div>Wyoming</div></li></ul><span class="super-dropdown-arrow"><span class="super-after"><i class="fas fa-caret-down"></i></span></span><span class="super-adaptive-placeholder" data-placeholder="- select a state -" data-placeholderFilled="- select a state -"><span>- select a state -</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div></div></div><div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  "><div class="super-label super-bottom-margin">Does the student have a medical ASD diagnosis? </div><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="ADS" data-oname="ADS" data-email="ADS:" data-absolute-default="" data-default-value="" /></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-heading   super-ungrouped  "><div class="super-heading-title"><h4>Responsible Caregiver Name</h4></div></div><div class="super-grid super-shortcode"><div class="super-shortcode super_one_half super-column grid-level-0 column-number-1 first-column "><div class="super-shortcode super-field super-text   super-ungrouped  "><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="first_namercn" data-oname="first_namercn" data-validation="empty" data-email="First Name RCN:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="First Name" data-placeholderFilled="First Name"><span>First Name</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div></div><div class="super-shortcode super_one_half super-column grid-level-0 column-number-2  "><div class="super-shortcode super-field super-text   super-ungrouped  "><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="last_namercn" data-oname="last_namercn" data-validation="empty" data-email="Last Name rcn:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Last Name" data-placeholderFilled="Last Name"><span>Last Name</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div></div></div><div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  "><div class="super-label super-bottom-margin">Phone Number</div><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="tel" name="phonenumber" data-oname="phonenumber" data-validation="phone" data-email="Phonenumber:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Phone Number " data-placeholderFilled="Phonenumber"><span>Phone Number </span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  "><div class="super-label super-bottom-margin">E-mail</div><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="email" name="email" data-oname="email" data-validation="email" data-email="E-mail RCN:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="E-mail" data-placeholderFilled="E-mail Address"><span>E-mail</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  "><div class="super-label super-bottom-margin">Name of Prescribing Physician </div><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="Name_of_Prescribing_Physician" data-oname="Name_of_Prescribing_Physician" data-email="Name of Prescribing Physician " data-absolute-default="" data-default-value="" /></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  "><div class="super-label super-bottom-margin">Dr. Phone number</div><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="tel" name="phonenumber_dr" data-oname="phonenumber_dr" data-validation="phone" data-email="DrPhonenumber:" data-absolute-default="" data-default-value="" /></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-dropdown super-has-only-label   super-ungrouped  "><div class="super-label super-bottom-margin">Hours available for ABA services (*10 hour minimum required):</div><div class="super-field-wrapper "><input type="hidden" class="super-shortcode-field" name="hours_aviable" value="" data-oname="hours_aviable" data-email="Hours available for ABA services (*10 hour minimum required):" data-absolute-default="" data-default-value="" /><input tabindex="-1" type="text" name="super-dropdown-search" value="" data-logic="contains" /><ul class="super-dropdown-list"><li data-value="" class="super-item super-placeholder">- select an option -</li><li class="super-item" data-value="Morning " data-search-value="Morning "><div>Morning </div></li><li class="super-item" data-value="4PM-7PM" data-search-value="4PM-7PM"><div>4PM-7PM</div></li><li class="super-item" data-value=" Weekend flexible" data-search-value=" Weekend flexible"><div> Weekend flexible</div></li><li class="super-item" data-value="Afternoon (11-3)" data-search-value="Afternoon (11-3)"><div>Afternoon (11-3)</div></li><li class="super-item" data-value="After 7PM" data-search-value="After 7PM"><div>After 7PM</div></li><li class="super-item" data-value="Other" data-search-value="Other"><div>Other</div></li></ul><span class="super-dropdown-arrow"><span class="super-after"><i class="fas fa-caret-down"></i></span></span><span class="super-adaptive-placeholder" data-placeholder="- select an option -" data-placeholderFilled="- select an option -"><span>- select an option -</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped   super-conditional-hidden" data-conditional-action="show" data-conditional-trigger="all"><div class="super-label super-bottom-margin">Other</div><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="otherHoursaviable" data-oname="otherHoursaviable" data-email="otherHoursaviable:" data-absolute-default="" data-default-value="" /></div><textarea class="super-conditional-logic" data-fields="{hours_aviable}">[{"field":"hours_aviable","logic":"equal","value":"Other","and_method":"","field_and":"","logic_and":"","value_and":""}]</textarea><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-checkbox super-has-only-label   super-ungrouped   display-vertical"><div class="super-label super-bottom-margin">Days Requesting Services (*4 days a week required)</div><div class="super-field-wrapper "><div class="super-items-list"><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value="monday" /><div>Monday</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value="Tuesday" /><div>Tuesday</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value="Wednesday" /><div>Wednesday</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value="Thursday" /><div>Thursday</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value=" Friday" /><div> Friday</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value="Saturday" /><div>Saturday</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value="Sunday" /><div>Sunday</div></label></div><input class="super-shortcode-field" type="hidden" name="days" value="" data-oname="days" data-validation="empty" data-email="Days Requesting Services (*4 days a week required):" data-absolute-default="" data-default-value="" data-admin-email-value="both" data-confirm-email-value="both" data-contact-entry-value="both" /></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-radio super-has-only-label   super-ungrouped   display-vertical"><div class="super-label super-bottom-margin">Referred by (allow us to thank them) </div><div class="super-field-wrapper "><div class="super-items-list"><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="Physician" /><div>Physician</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value=" Google/Internet Search" /><div> Google/Internet Search</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="Friend" /><div>Friend</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="Esti/ Intake Coordinator" /><div>Esti/ Intake Coordinator</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="other" /><div>Other</div></label></div><input class="super-shortcode-field" type="hidden" name="Referredfield" value="" data-oname="Referredfield" data-email="Referred by (allow us to thank them) :" data-absolute-default="" data-default-value="" /></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped   super-conditional-hidden" data-conditional-action="show" data-conditional-trigger="all"><div class="super-label super-bottom-margin">Other</div><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="otherreferred" data-oname="otherreferred" data-email="otherreferred" data-absolute-default="" data-default-value="" /></div><textarea class="super-conditional-logic" data-fields="{Referredfield}">[{"field":"{Referredfield}","logic":"equal","value":"other","and_method":"","field_and":"","logic_and":"","value_and":""}]</textarea><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-textarea super-has-only-label   super-ungrouped  "><div class="super-label super-bottom-margin">Additional Comments</div><div class="super-field-wrapper "><textarea tabindex="-1" class="super-shortcode-field" name="Additional_Comments" data-oname="Additional_Comments" data-email="Additional Comments:" data-absolute-default="" data-default-value="" ></textarea><span class="super-adaptive-placeholder" data-placeholder="Please provide us with any relevant information that may be important" data-placeholderFilled="Question"><span>Please provide us with any relevant information that may be important</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div style="padding-top:20px;padding-bottom:20px;" class="super-shortcode super-field super-divider  super-align-left  super-ungrouped   align-left border-single style-dashed back-0"><div class="super-divider-inner" style="width:100%;border-color:#444444;border-top-width:1px;border-bottom-width:1px;height:1px;"></div></div><div class="super-shortcode super-field super-heading   super-ungrouped  "><div class="super-heading-title"><h1>Parent(s)/Legal Guardian Information</h1></div></div><div class="super-shortcode super-field super-heading   super-ungrouped  "><div class="super-heading-title"><h4>Caregiver Name</h4></div></div><div class="super-grid super-shortcode"><div class="super-shortcode super_one_half super-column grid-level-0 column-number-1 first-column "><div class="super-shortcode super-field super-text   super-ungrouped  "><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="first_namec" data-oname="first_namec" data-validation="empty" data-email="First Name C:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="First Name" data-placeholderFilled="First Name"><span>First Name</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div></div><div class="super-shortcode super_one_half super-column grid-level-0 column-number-2  "><div class="super-shortcode super-field super-text   super-ungrouped  "><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="last_nameC" data-oname="last_nameC" data-validation="empty" data-email="Last Name C:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Last Name" data-placeholderFilled="Last Name"><span>Last Name</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div></div></div><div class="super-shortcode super-field super-text   super-ungrouped  "><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="tel" name="phonenumber_c" data-oname="phonenumber_c" data-validation="phone" data-email="PhonenumbeCr:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Phone Number" data-placeholderFilled="Phonenumber"><span>Phone Number</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-text   super-ungrouped  "><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="email" name="email_c" data-oname="email_c" data-validation="email" data-email="Email addressC:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="E-mail Address" data-placeholderFilled="E-mail Address"><span>E-mail Address</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div style="padding-top:20px;padding-bottom:20px;" class="super-shortcode super-field super-divider  super-align-left  super-ungrouped   align-left border-single style-dashed back-0"><div class="super-divider-inner" style="width:100%;border-color:#444444;border-top-width:1px;border-bottom-width:1px;height:1px;"></div></div><div class="super-shortcode super-field super-heading   super-ungrouped  "><div class="super-heading-title"><h1>Insurance Information</h1></div></div><div style="padding-top:20px;padding-bottom:20px;" class="super-shortcode super-field super-divider  super-align-left  super-ungrouped   align-left border-single style-dashed back-0"><div class="super-divider-inner" style="width:100%;border-color:#444444;border-top-width:1px;border-bottom-width:1px;height:1px;"></div></div><div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  "><div class="super-label super-bottom-margin">Primary Policyholder Name: </div><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="Primary_Policyholder_Name" data-oname="Primary_Policyholder_Name" data-email="Primary Policyholder Name:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Primary Policyholder Name: " data-placeholderFilled="Name"><span>Primary Policyholder Name: </span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-grid super-shortcode"><div class="super-shortcode super_one_half super-column grid-level-0 column-number-1 first-column "><div class="super-shortcode super-field super-radio super-has-only-label   super-ungrouped   display-vertical"><div class="super-label super-bottom-margin">Relationship to Student</div><div class="super-field-wrapper "><div class="super-items-list"><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="Mother" /><div>Mother</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="Father" /><div>Father</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="Self" /><div>Self</div></label></div><input class="super-shortcode-field" type="hidden" name="relation" value="" data-oname="relation" data-email="Relationship to Student:" data-absolute-default="" data-default-value="" /></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div></div><div class="super-shortcode super_one_half super-column grid-level-0 column-number-2  "><div class="super-shortcode super-field super-text   super-ungrouped  "><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="otherrs" data-oname="otherrs" data-email="Relationship to Student Other:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Other" data-placeholderFilled="Name"><span>Other</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div></div></div><div class="super-shortcode super-field super-date super-has-only-label   super-ungrouped  "><div class="super-label super-bottom-margin">Policyholder DOB</div><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field super-datepicker" type="text" autocomplete="false"  value="" 
        name="Policyholder_DOB" 
        data-format="dd-mm-yy" 
        data-jsformat="dd-MM-yyyy" 
        data-connected-min="" 
        data-connected-min-days="1" 
        data-connected-max="" 
        data-connected-max-days="1" 
        data-range="-100:+5" 
        data-first-day="1"
        data-localization=""
        data-change-month="true"
        data-change-year="true"
        data-show-month-after-year=""
        data-show-week=""
        data-number-of-months="1"
        data-show-other-months=""
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<p>La entrada <a href="https://leadersabatherapy.com/service/counseling/">COUNSELING</a> se publicó primero en <a href="https://leadersabatherapy.com">Leaders Behavior ABA &amp; Counseling, LLC</a>.</p>
]]></content:encoded>
					
		
		
			</item>
		<item>
		<title>TARGETED CASE MANAGEMENT</title>
		<link>https://leadersabatherapy.com/service/targeted-case-management/</link>
		
		<dc:creator><![CDATA[admin]]></dc:creator>
		<pubDate>Wed, 05 Jul 2017 10:29:52 +0000</pubDate>
				<guid isPermaLink="false">http://capital.imithemes.com/demo1/?post_type=imi_services&#038;p=60</guid>

					<description><![CDATA[<p>Social work case management is a method of providing services whereby a professional social worker assesses the needs of the client and the client's family, when appropriate, and arranges, coordinates, monitors., evaluates, and advocates for a package of multiple services to meet the specific client's complex needs.</p>
<p>La entrada <a href="https://leadersabatherapy.com/service/targeted-case-management/">TARGETED CASE MANAGEMENT</a> se publicó primero en <a href="https://leadersabatherapy.com">Leaders Behavior ABA &amp; Counseling, LLC</a>.</p>
]]></description>
										<content:encoded><![CDATA[<div class="vc_row wpb_row vc_row-fluid"><div class="wpb_column vc_column_container vc_col-sm-12"><div class="vc_column-inner"><div class="wpb_wrapper"></div></div></div></div><div class="vc_row wpb_row vc_row-fluid"><div class="wpb_column vc_column_container vc_col-sm-6"><div class="vc_column-inner"><div class="wpb_wrapper"><h2 style="text-align: left" class="vc_custom_heading" >TARGETED CASE MANAGEMENT</h2>
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			<p><strong>Social work case management is</strong> a method of providing <strong>services</strong> whereby a professional <strong>social worker</strong> assesses the needs of the client and the client&#8217;s family when appropriate and arranges, coordinates, monitors., evaluates, and advocates for a package of multiple <strong>services</strong> to meet the specific client&#8217;s complex needs.</p>

		</div>
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			<div class="vc_single_image-wrapper   vc_box_border_grey"><img loading="lazy" decoding="async" width="600" height="450" src="https://leadersabatherapy.com/wp-content/uploads/2020/12/c56-1.jpg" class="vc_single_image-img attachment-full" alt="" srcset="https://leadersabatherapy.com/wp-content/uploads/2020/12/c56-1.jpg 600w, https://leadersabatherapy.com/wp-content/uploads/2020/12/c56-1-300x225.jpg 300w" sizes="(max-width: 600px) 100vw, 600px" /></div>
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</div></div></div></div><div class="vc_row wpb_row vc_row-fluid"><div class="wpb_column vc_column_container vc_col-sm-12"><div class="vc_column-inner"><div class="wpb_wrapper"><h2 style="text-align: left;font-family:Abril Fatface;font-weight:400;font-style:normal" class="vc_custom_heading" >REQUEST SERVICE</h2>
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			<style type="text/css">.super-form:not(.super-initialized) *:not(.super-load-icon) { visibility: hidden !important; }</style><div id="super-form-831" style="margin:0px 0px 0px 0px;" class="super-form super-form-831  super-default-rounded super-field-size-medium super-adaptive" data-hide="true" data-overlay="true" data-field-size="medium"><span class="super-load-icon"></span><form tabindex="0" autocomplete="on" enctype="multipart/form-data"><input type="hidden" name="sf_nonce" value="" /><input type="text" name="super_hp" size="25" value="" /><div class="super-shortcode super-field super-hidden"><input class="super-shortcode-field" type="hidden" value="831" name="hidden_form_id" /></div><div class="super-shortcode super-field super-heading   super-ungrouped  "><div class="super-heading-title"><h1>Insurance Intake & Verification Form</h1></div><div class="super-heading-description" ><div>Student/Caregiver Information</div></div></div><div style="padding-top:20px;padding-bottom:20px;" class="super-shortcode super-field super-divider  super-align-left  super-ungrouped   align-left border-single style-dashed back-0"><div class="super-divider-inner" style="width:100%;border-color:#444444;border-top-width:1px;border-bottom-width:1px;height:1px;"></div></div><div class="super-shortcode super-field super-heading   super-ungrouped  "><div class="super-heading-title"><h4>Student Name</h4></div></div><div class="super-grid super-shortcode"><div class="super-shortcode super_one_half super-column grid-level-0 column-number-1 first-column "><div class="super-shortcode super-field super-text   super-ungrouped  "><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="first_name" data-oname="first_name" data-validation="empty" data-email="First Name:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="First Name" data-placeholderFilled="First Name"><span>First Name</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div></div><div class="super-shortcode super_one_half super-column grid-level-0 column-number-2  "><div class="super-shortcode super-field super-text   super-ungrouped  "><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="last_name" data-oname="last_name" data-validation="empty" data-email="Last Name:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Last Name" data-placeholderFilled="Last Name"><span>Last Name</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div></div></div><div class="super-shortcode super-field super-date super-has-only-label   super-ungrouped  "><div class="super-label super-bottom-margin">Date of Birth</div><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field super-datepicker" type="text" autocomplete="false"  value="" 
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        data-connected-max-days="1" 
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"><input tabindex="-1" class="super-shortcode-field" type="text" name="address1" data-oname="address1" data-validation="empty" data-email="Address:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder=" Street Address " data-placeholderFilled="Address"><span> Street Address </span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-text   super-ungrouped  "><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="address2" data-oname="address2" data-validation="empty" data-email="Address 2:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Street Address Line 2" data-placeholderFilled="Address"><span>Street Address Line 2</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-grid super-shortcode"><div class="super-shortcode super_one_third super-column grid-level-0 column-number-1 first-column "><div class="super-shortcode super-field super-text   super-ungrouped  "><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="zipcode" data-oname="zipcode" data-validation="empty" data-email="Zipcode:" data-absolute-default="" data-default-value="" data-minlength="4" /><span class="super-adaptive-placeholder" data-placeholder="Zipcode" data-placeholderFilled="Zipcode"><span>Zipcode</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div></div><div class="super-shortcode super_one_third super-column grid-level-0 column-number-2  "><div class="super-shortcode super-field super-text   super-ungrouped  "><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="city" data-oname="city" data-validation="empty" data-email="City:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="City" data-placeholderFilled="City"><span>City</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div></div><div class="super-shortcode super_one_third super-column grid-level-0 column-number-3  "><div class="super-shortcode super-field super-dropdown   super-ungrouped  "><div class="super-field-wrapper "><input type="hidden" class="super-shortcode-field" name="state" value="" data-oname="state" data-email="State:" data-absolute-default="" data-default-value="" /><input tabindex="-1" type="text" name="super-dropdown-search" value="" data-logic="contains" /><ul class="super-dropdown-list"><li data-value="" class="super-item super-placeholder">- select a state -</li><li class="super-item" data-value="AL" data-search-value="Alabama"><div>Alabama</div></li><li class="super-item" data-value="AK" data-search-value="Alaska"><div>Alaska</div></li><li class="super-item" data-value="AZ" data-search-value="Arizona"><div>Arizona</div></li><li class="super-item" data-value="AR" data-search-value="Arkansas"><div>Arkansas</div></li><li class="super-item" data-value="CA" data-search-value="California"><div>California</div></li><li class="super-item" data-value="CO" data-search-value="Colorado"><div>Colorado</div></li><li class="super-item" data-value="CT" data-search-value="Connecticut"><div>Connecticut</div></li><li class="super-item" data-value="DE" data-search-value="Delaware"><div>Delaware</div></li><li class="super-item" data-value="DC" data-search-value="District of Columbia"><div>District of Columbia</div></li><li class="super-item" data-value="FL" data-search-value="Florida"><div>Florida</div></li><li class="super-item" data-value="GA" data-search-value="Georgia"><div>Georgia</div></li><li class="super-item" data-value="HI" data-search-value="Hawaii"><div>Hawaii</div></li><li class="super-item" data-value="ID" data-search-value="Idaho"><div>Idaho</div></li><li class="super-item" data-value="IL" data-search-value="Illinois"><div>Illinois</div></li><li class="super-item" data-value="IN" data-search-value="Indiana"><div>Indiana</div></li><li class="super-item" data-value="IA" data-search-value="Iowa"><div>Iowa</div></li><li class="super-item" data-value="KS" data-search-value="Kansas"><div>Kansas</div></li><li class="super-item" data-value="KY" data-search-value="Kentucky"><div>Kentucky</div></li><li class="super-item" data-value="LA" data-search-value="Louisiana"><div>Louisiana</div></li><li class="super-item" data-value="ME" data-search-value="Maine"><div>Maine</div></li><li class="super-item" data-value="MD" data-search-value="Maryland"><div>Maryland</div></li><li class="super-item" data-value="MA" data-search-value="Massachusetts"><div>Massachusetts</div></li><li class="super-item" data-value="MI" data-search-value="Michigan"><div>Michigan</div></li><li class="super-item" data-value="MN" data-search-value="Minnesota"><div>Minnesota</div></li><li class="super-item" data-value="MS" data-search-value="Mississippi"><div>Mississippi</div></li><li class="super-item" data-value="MO" data-search-value="Missouri"><div>Missouri</div></li><li class="super-item" data-value="MT" data-search-value="Montana"><div>Montana</div></li><li class="super-item" data-value="NE" data-search-value="Nebraska"><div>Nebraska</div></li><li class="super-item" data-value="NV" data-search-value="Nevada"><div>Nevada</div></li><li class="super-item" data-value="NH" data-search-value="New Hampshire"><div>New Hampshire</div></li><li class="super-item" data-value="NJ" data-search-value="New Jersey"><div>New Jersey</div></li><li class="super-item" data-value="NM" data-search-value="New Mexico"><div>New Mexico</div></li><li class="super-item" data-value="NY" data-search-value="New York"><div>New York</div></li><li class="super-item" data-value="NC" data-search-value="North Carolina"><div>North Carolina</div></li><li class="super-item" data-value="ND" data-search-value="North Dakota"><div>North Dakota</div></li><li class="super-item" data-value="OH" data-search-value="Ohio"><div>Ohio</div></li><li class="super-item" data-value="OK" data-search-value="Oklahoma"><div>Oklahoma</div></li><li class="super-item" data-value="OR" data-search-value="Oregon"><div>Oregon</div></li><li class="super-item" data-value="PA" data-search-value="Pennsylvania"><div>Pennsylvania</div></li><li class="super-item" data-value="RI" data-search-value="Rhode Island"><div>Rhode Island</div></li><li class="super-item" data-value="SC" data-search-value="South Carolina"><div>South Carolina</div></li><li class="super-item" data-value="SD" data-search-value="South Dakota"><div>South Dakota</div></li><li class="super-item" data-value="TN" data-search-value="Tennessee"><div>Tennessee</div></li><li class="super-item" data-value="TX" data-search-value="Texas"><div>Texas</div></li><li class="super-item" data-value="UT" data-search-value="Utah"><div>Utah</div></li><li class="super-item" data-value="VT" data-search-value="Vermont"><div>Vermont</div></li><li class="super-item" data-value="VA" data-search-value="Virginia"><div>Virginia</div></li><li class="super-item" data-value="WA" data-search-value="Washington"><div>Washington</div></li><li class="super-item" data-value="WV" data-search-value="West Virginia"><div>West Virginia</div></li><li class="super-item" data-value="WI" data-search-value="Wisconsin"><div>Wisconsin</div></li><li class="super-item" data-value="WY" data-search-value="Wyoming"><div>Wyoming</div></li></ul><span class="super-dropdown-arrow"><span class="super-after"><i class="fas fa-caret-down"></i></span></span><span class="super-adaptive-placeholder" data-placeholder="- select a state -" data-placeholderFilled="- select a state -"><span>- select a state -</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div></div></div><div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  "><div class="super-label super-bottom-margin">Does the student have a medical ASD diagnosis? </div><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="ADS" data-oname="ADS" data-email="ADS:" data-absolute-default="" data-default-value="" /></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-heading   super-ungrouped  "><div class="super-heading-title"><h4>Responsible Caregiver Name</h4></div></div><div class="super-grid super-shortcode"><div class="super-shortcode super_one_half super-column grid-level-0 column-number-1 first-column "><div class="super-shortcode super-field super-text   super-ungrouped  "><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="first_namercn" data-oname="first_namercn" data-validation="empty" data-email="First Name RCN:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="First Name" data-placeholderFilled="First Name"><span>First Name</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div></div><div class="super-shortcode super_one_half super-column grid-level-0 column-number-2  "><div class="super-shortcode super-field super-text   super-ungrouped  "><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="last_namercn" data-oname="last_namercn" data-validation="empty" data-email="Last Name rcn:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Last Name" data-placeholderFilled="Last Name"><span>Last Name</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div></div></div><div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  "><div class="super-label super-bottom-margin">Phone Number</div><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="tel" name="phonenumber" data-oname="phonenumber" data-validation="phone" data-email="Phonenumber:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Phone Number " data-placeholderFilled="Phonenumber"><span>Phone Number </span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  "><div class="super-label super-bottom-margin">E-mail</div><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="email" name="email" data-oname="email" data-validation="email" data-email="E-mail RCN:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="E-mail" data-placeholderFilled="E-mail Address"><span>E-mail</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  "><div class="super-label super-bottom-margin">Name of Prescribing Physician </div><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="Name_of_Prescribing_Physician" data-oname="Name_of_Prescribing_Physician" data-email="Name of Prescribing Physician " data-absolute-default="" data-default-value="" /></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  "><div class="super-label super-bottom-margin">Dr. Phone number</div><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="tel" name="phonenumber_dr" data-oname="phonenumber_dr" data-validation="phone" data-email="DrPhonenumber:" data-absolute-default="" data-default-value="" /></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-dropdown super-has-only-label   super-ungrouped  "><div class="super-label super-bottom-margin">Hours available for ABA services (*10 hour minimum required):</div><div class="super-field-wrapper "><input type="hidden" class="super-shortcode-field" name="hours_aviable" value="" data-oname="hours_aviable" data-email="Hours available for ABA services (*10 hour minimum required):" data-absolute-default="" data-default-value="" /><input tabindex="-1" type="text" name="super-dropdown-search" value="" data-logic="contains" /><ul class="super-dropdown-list"><li data-value="" class="super-item super-placeholder">- select an option -</li><li class="super-item" data-value="Morning " data-search-value="Morning "><div>Morning </div></li><li class="super-item" data-value="4PM-7PM" data-search-value="4PM-7PM"><div>4PM-7PM</div></li><li class="super-item" data-value=" Weekend flexible" data-search-value=" Weekend flexible"><div> Weekend flexible</div></li><li class="super-item" data-value="Afternoon (11-3)" data-search-value="Afternoon (11-3)"><div>Afternoon (11-3)</div></li><li class="super-item" data-value="After 7PM" data-search-value="After 7PM"><div>After 7PM</div></li><li class="super-item" data-value="Other" data-search-value="Other"><div>Other</div></li></ul><span class="super-dropdown-arrow"><span class="super-after"><i class="fas fa-caret-down"></i></span></span><span class="super-adaptive-placeholder" data-placeholder="- select an option -" data-placeholderFilled="- select an option -"><span>- select an option -</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped   super-conditional-hidden" data-conditional-action="show" data-conditional-trigger="all"><div class="super-label super-bottom-margin">Other</div><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="otherHoursaviable" data-oname="otherHoursaviable" data-email="otherHoursaviable:" data-absolute-default="" data-default-value="" /></div><textarea class="super-conditional-logic" data-fields="{hours_aviable}">[{"field":"hours_aviable","logic":"equal","value":"Other","and_method":"","field_and":"","logic_and":"","value_and":""}]</textarea><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-checkbox super-has-only-label   super-ungrouped   display-vertical"><div class="super-label super-bottom-margin">Days Requesting Services (*4 days a week required)</div><div class="super-field-wrapper "><div class="super-items-list"><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value="monday" /><div>Monday</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value="Tuesday" /><div>Tuesday</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value="Wednesday" /><div>Wednesday</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value="Thursday" /><div>Thursday</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value=" Friday" /><div> Friday</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value="Saturday" /><div>Saturday</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value="Sunday" /><div>Sunday</div></label></div><input class="super-shortcode-field" type="hidden" name="days" value="" data-oname="days" data-validation="empty" data-email="Days Requesting Services (*4 days a week required):" data-absolute-default="" data-default-value="" data-admin-email-value="both" data-confirm-email-value="both" data-contact-entry-value="both" /></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-radio super-has-only-label   super-ungrouped   display-vertical"><div class="super-label super-bottom-margin">Referred by (allow us to thank them) </div><div class="super-field-wrapper "><div class="super-items-list"><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="Physician" /><div>Physician</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value=" Google/Internet Search" /><div> Google/Internet Search</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="Friend" /><div>Friend</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="Esti/ Intake Coordinator" /><div>Esti/ Intake Coordinator</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="other" /><div>Other</div></label></div><input class="super-shortcode-field" type="hidden" name="Referredfield" value="" data-oname="Referredfield" data-email="Referred by (allow us to thank them) :" data-absolute-default="" data-default-value="" /></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped   super-conditional-hidden" data-conditional-action="show" data-conditional-trigger="all"><div class="super-label super-bottom-margin">Other</div><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="otherreferred" data-oname="otherreferred" data-email="otherreferred" data-absolute-default="" data-default-value="" /></div><textarea class="super-conditional-logic" data-fields="{Referredfield}">[{"field":"{Referredfield}","logic":"equal","value":"other","and_method":"","field_and":"","logic_and":"","value_and":""}]</textarea><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-textarea super-has-only-label   super-ungrouped  "><div class="super-label super-bottom-margin">Additional Comments</div><div class="super-field-wrapper "><textarea tabindex="-1" class="super-shortcode-field" name="Additional_Comments" data-oname="Additional_Comments" data-email="Additional Comments:" data-absolute-default="" data-default-value="" ></textarea><span class="super-adaptive-placeholder" data-placeholder="Please provide us with any relevant information that may be important" data-placeholderFilled="Question"><span>Please provide us with any relevant information that may be important</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div style="padding-top:20px;padding-bottom:20px;" class="super-shortcode super-field super-divider  super-align-left  super-ungrouped   align-left border-single style-dashed back-0"><div class="super-divider-inner" style="width:100%;border-color:#444444;border-top-width:1px;border-bottom-width:1px;height:1px;"></div></div><div class="super-shortcode super-field super-heading   super-ungrouped  "><div class="super-heading-title"><h1>Parent(s)/Legal Guardian Information</h1></div></div><div class="super-shortcode super-field super-heading   super-ungrouped  "><div class="super-heading-title"><h4>Caregiver Name</h4></div></div><div class="super-grid super-shortcode"><div class="super-shortcode super_one_half super-column grid-level-0 column-number-1 first-column "><div class="super-shortcode super-field super-text   super-ungrouped  "><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="first_namec" data-oname="first_namec" data-validation="empty" data-email="First Name C:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="First Name" data-placeholderFilled="First Name"><span>First Name</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div></div><div class="super-shortcode super_one_half super-column grid-level-0 column-number-2  "><div class="super-shortcode super-field super-text   super-ungrouped  "><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="last_nameC" data-oname="last_nameC" data-validation="empty" data-email="Last Name C:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Last Name" data-placeholderFilled="Last Name"><span>Last Name</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div></div></div><div class="super-shortcode super-field super-text   super-ungrouped  "><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="tel" name="phonenumber_c" data-oname="phonenumber_c" data-validation="phone" data-email="PhonenumbeCr:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Phone Number" data-placeholderFilled="Phonenumber"><span>Phone Number</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-text   super-ungrouped  "><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="email" name="email_c" data-oname="email_c" data-validation="email" data-email="Email addressC:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="E-mail Address" data-placeholderFilled="E-mail Address"><span>E-mail Address</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div style="padding-top:20px;padding-bottom:20px;" class="super-shortcode super-field super-divider  super-align-left  super-ungrouped   align-left border-single style-dashed back-0"><div class="super-divider-inner" style="width:100%;border-color:#444444;border-top-width:1px;border-bottom-width:1px;height:1px;"></div></div><div class="super-shortcode super-field super-heading   super-ungrouped  "><div class="super-heading-title"><h1>Insurance Information</h1></div></div><div style="padding-top:20px;padding-bottom:20px;" class="super-shortcode super-field super-divider  super-align-left  super-ungrouped   align-left border-single style-dashed back-0"><div class="super-divider-inner" style="width:100%;border-color:#444444;border-top-width:1px;border-bottom-width:1px;height:1px;"></div></div><div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  "><div class="super-label super-bottom-margin">Primary Policyholder Name: </div><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="Primary_Policyholder_Name" data-oname="Primary_Policyholder_Name" data-email="Primary Policyholder Name:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Primary Policyholder Name: " data-placeholderFilled="Name"><span>Primary Policyholder Name: </span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-grid super-shortcode"><div class="super-shortcode super_one_half super-column grid-level-0 column-number-1 first-column "><div class="super-shortcode super-field super-radio super-has-only-label   super-ungrouped   display-vertical"><div class="super-label super-bottom-margin">Relationship to Student</div><div class="super-field-wrapper "><div class="super-items-list"><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="Mother" /><div>Mother</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="Father" /><div>Father</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="Self" /><div>Self</div></label></div><input class="super-shortcode-field" type="hidden" name="relation" value="" data-oname="relation" data-email="Relationship to Student:" data-absolute-default="" data-default-value="" /></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div></div><div class="super-shortcode super_one_half super-column grid-level-0 column-number-2  "><div class="super-shortcode super-field super-text   super-ungrouped  "><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="otherrs" data-oname="otherrs" data-email="Relationship to Student Other:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Other" data-placeholderFilled="Name"><span>Other</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div></div></div><div class="super-shortcode super-field super-date super-has-only-label   super-ungrouped  "><div class="super-label super-bottom-margin">Policyholder DOB</div><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field super-datepicker" type="text" autocomplete="false"  value="" 
        name="Policyholder_DOB" 
        data-format="dd-mm-yy" 
        data-jsformat="dd-MM-yyyy" 
        data-connected-min="" 
        data-connected-min-days="1" 
        data-connected-max="" 
        data-connected-max-days="1" 
        data-range="-100:+5" 
        data-first-day="1"
        data-localization=""
        data-change-month="true"
        data-change-year="true"
        data-show-month-after-year=""
        data-show-week=""
        data-number-of-months="1"
        data-show-other-months=""
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		</div>
	</div>
</div></div></div></div>
<p>La entrada <a href="https://leadersabatherapy.com/service/targeted-case-management/">TARGETED CASE MANAGEMENT</a> se publicó primero en <a href="https://leadersabatherapy.com">Leaders Behavior ABA &amp; Counseling, LLC</a>.</p>
]]></content:encoded>
					
		
		
			</item>
		<item>
		<title>SUPERVISION BY BOARD CERTIFIED BEHAVIOR ANALYST (BCBA) FOR BCBA´S AND RBT.</title>
		<link>https://leadersabatherapy.com/service/supervision-by-board-certified-behavior-analyst-bcbas-for-bcabas-and-rbts/</link>
		
		<dc:creator><![CDATA[admin]]></dc:creator>
		<pubDate>Wed, 05 Jul 2017 10:14:37 +0000</pubDate>
				<guid isPermaLink="false">http://capital.imithemes.com/demo1/?post_type=imi_services&#038;p=58</guid>

					<description><![CDATA[<p>La entrada <a href="https://leadersabatherapy.com/service/supervision-by-board-certified-behavior-analyst-bcbas-for-bcabas-and-rbts/">SUPERVISION BY BOARD CERTIFIED BEHAVIOR ANALYST (BCBA) FOR BCBA´S AND RBT.</a> se publicó primero en <a href="https://leadersabatherapy.com">Leaders Behavior ABA &amp; Counseling, LLC</a>.</p>
]]></description>
										<content:encoded><![CDATA[<div class="vc_row wpb_row vc_row-fluid"><div class="wpb_column vc_column_container vc_col-sm-6"><div class="vc_column-inner"><div class="wpb_wrapper"><h2 style="text-align: left" class="vc_custom_heading" >Workforce Optimization</h2>
	<div class="wpb_text_column wpb_content_element " >
		<div class="wpb_wrapper">
			<ul>
<li>SUPERVISION BY BOARD CERTIFIED BEHAVIOR ANALYST (BCBA) FOR BCBA´S AND RBT.</li>
</ul>

		</div>
	</div>
</div></div></div><div class="wpb_column vc_column_container vc_col-sm-6"><div class="vc_column-inner"><div class="wpb_wrapper">
	<div  class="wpb_single_image wpb_content_element vc_align_left">
		
		<figure class="wpb_wrapper vc_figure">
			<div class="vc_single_image-wrapper   vc_box_border_grey"><img loading="lazy" decoding="async" width="600" height="450" src="https://leadersabatherapy.com/wp-content/uploads/2017/07/target.jpg" class="vc_single_image-img attachment-full" alt="" srcset="https://leadersabatherapy.com/wp-content/uploads/2017/07/target.jpg 600w, https://leadersabatherapy.com/wp-content/uploads/2017/07/target-300x225.jpg 300w" sizes="(max-width: 600px) 100vw, 600px" /></div>
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	</div>
</div></div></div></div><div class="vc_row wpb_row vc_row-fluid"><div class="wpb_column vc_column_container vc_col-sm-12"><div class="vc_column-inner"><div class="wpb_wrapper"><h2 style="text-align: left;font-family:Abril Fatface;font-weight:400;font-style:normal" class="vc_custom_heading" >REQUEST SERVICE </h2>
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class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-grid super-shortcode"><div class="super-shortcode super_one_third super-column grid-level-0 column-number-1 first-column "><div class="super-shortcode super-field super-text   super-ungrouped  "><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="zipcode" data-oname="zipcode" data-validation="empty" data-email="Zipcode:" data-absolute-default="" data-default-value="" data-minlength="4" /><span class="super-adaptive-placeholder" data-placeholder="Zipcode" data-placeholderFilled="Zipcode"><span>Zipcode</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div></div><div class="super-shortcode super_one_third super-column grid-level-0 column-number-2  "><div class="super-shortcode super-field super-text   super-ungrouped  "><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="city" data-oname="city" data-validation="empty" data-email="City:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="City" data-placeholderFilled="City"><span>City</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div></div><div class="super-shortcode super_one_third super-column grid-level-0 column-number-3  "><div class="super-shortcode super-field super-dropdown   super-ungrouped  "><div class="super-field-wrapper "><input type="hidden" class="super-shortcode-field" name="state" value="" data-oname="state" data-email="State:" data-absolute-default="" data-default-value="" /><input tabindex="-1" type="text" name="super-dropdown-search" value="" data-logic="contains" /><ul class="super-dropdown-list"><li data-value="" class="super-item super-placeholder">- select a state -</li><li class="super-item" data-value="AL" data-search-value="Alabama"><div>Alabama</div></li><li class="super-item" data-value="AK" data-search-value="Alaska"><div>Alaska</div></li><li class="super-item" data-value="AZ" data-search-value="Arizona"><div>Arizona</div></li><li class="super-item" data-value="AR" data-search-value="Arkansas"><div>Arkansas</div></li><li class="super-item" data-value="CA" data-search-value="California"><div>California</div></li><li class="super-item" data-value="CO" data-search-value="Colorado"><div>Colorado</div></li><li class="super-item" data-value="CT" data-search-value="Connecticut"><div>Connecticut</div></li><li class="super-item" data-value="DE" data-search-value="Delaware"><div>Delaware</div></li><li class="super-item" data-value="DC" data-search-value="District of Columbia"><div>District of Columbia</div></li><li class="super-item" data-value="FL" data-search-value="Florida"><div>Florida</div></li><li class="super-item" data-value="GA" data-search-value="Georgia"><div>Georgia</div></li><li class="super-item" data-value="HI" data-search-value="Hawaii"><div>Hawaii</div></li><li class="super-item" data-value="ID" data-search-value="Idaho"><div>Idaho</div></li><li class="super-item" data-value="IL" data-search-value="Illinois"><div>Illinois</div></li><li class="super-item" data-value="IN" data-search-value="Indiana"><div>Indiana</div></li><li class="super-item" data-value="IA" data-search-value="Iowa"><div>Iowa</div></li><li class="super-item" data-value="KS" data-search-value="Kansas"><div>Kansas</div></li><li class="super-item" data-value="KY" data-search-value="Kentucky"><div>Kentucky</div></li><li class="super-item" data-value="LA" data-search-value="Louisiana"><div>Louisiana</div></li><li class="super-item" data-value="ME" data-search-value="Maine"><div>Maine</div></li><li class="super-item" data-value="MD" data-search-value="Maryland"><div>Maryland</div></li><li class="super-item" data-value="MA" data-search-value="Massachusetts"><div>Massachusetts</div></li><li class="super-item" data-value="MI" data-search-value="Michigan"><div>Michigan</div></li><li class="super-item" data-value="MN" data-search-value="Minnesota"><div>Minnesota</div></li><li class="super-item" data-value="MS" data-search-value="Mississippi"><div>Mississippi</div></li><li class="super-item" data-value="MO" data-search-value="Missouri"><div>Missouri</div></li><li class="super-item" data-value="MT" data-search-value="Montana"><div>Montana</div></li><li class="super-item" data-value="NE" data-search-value="Nebraska"><div>Nebraska</div></li><li class="super-item" data-value="NV" data-search-value="Nevada"><div>Nevada</div></li><li class="super-item" data-value="NH" data-search-value="New Hampshire"><div>New Hampshire</div></li><li class="super-item" data-value="NJ" data-search-value="New Jersey"><div>New Jersey</div></li><li class="super-item" data-value="NM" data-search-value="New Mexico"><div>New Mexico</div></li><li class="super-item" data-value="NY" data-search-value="New York"><div>New York</div></li><li class="super-item" data-value="NC" data-search-value="North Carolina"><div>North Carolina</div></li><li class="super-item" data-value="ND" data-search-value="North Dakota"><div>North Dakota</div></li><li class="super-item" data-value="OH" data-search-value="Ohio"><div>Ohio</div></li><li class="super-item" data-value="OK" data-search-value="Oklahoma"><div>Oklahoma</div></li><li class="super-item" data-value="OR" data-search-value="Oregon"><div>Oregon</div></li><li class="super-item" data-value="PA" data-search-value="Pennsylvania"><div>Pennsylvania</div></li><li class="super-item" data-value="RI" data-search-value="Rhode Island"><div>Rhode Island</div></li><li class="super-item" data-value="SC" data-search-value="South Carolina"><div>South Carolina</div></li><li class="super-item" data-value="SD" data-search-value="South Dakota"><div>South Dakota</div></li><li class="super-item" data-value="TN" data-search-value="Tennessee"><div>Tennessee</div></li><li class="super-item" data-value="TX" data-search-value="Texas"><div>Texas</div></li><li class="super-item" data-value="UT" data-search-value="Utah"><div>Utah</div></li><li class="super-item" data-value="VT" data-search-value="Vermont"><div>Vermont</div></li><li class="super-item" data-value="VA" data-search-value="Virginia"><div>Virginia</div></li><li class="super-item" data-value="WA" data-search-value="Washington"><div>Washington</div></li><li class="super-item" data-value="WV" data-search-value="West Virginia"><div>West Virginia</div></li><li class="super-item" data-value="WI" data-search-value="Wisconsin"><div>Wisconsin</div></li><li class="super-item" data-value="WY" data-search-value="Wyoming"><div>Wyoming</div></li></ul><span class="super-dropdown-arrow"><span class="super-after"><i class="fas fa-caret-down"></i></span></span><span class="super-adaptive-placeholder" data-placeholder="- select a state -" data-placeholderFilled="- select a state -"><span>- select a state -</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div></div></div><div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  "><div class="super-label super-bottom-margin">Does the student have a medical ASD diagnosis? </div><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="ADS" data-oname="ADS" data-email="ADS:" data-absolute-default="" data-default-value="" /></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-heading   super-ungrouped  "><div class="super-heading-title"><h4>Responsible Caregiver Name</h4></div></div><div class="super-grid super-shortcode"><div class="super-shortcode super_one_half super-column grid-level-0 column-number-1 first-column "><div class="super-shortcode super-field super-text   super-ungrouped  "><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="first_namercn" data-oname="first_namercn" data-validation="empty" data-email="First Name RCN:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="First Name" data-placeholderFilled="First Name"><span>First Name</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div></div><div class="super-shortcode super_one_half super-column grid-level-0 column-number-2  "><div class="super-shortcode super-field super-text   super-ungrouped  "><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="last_namercn" data-oname="last_namercn" data-validation="empty" data-email="Last Name rcn:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Last Name" data-placeholderFilled="Last Name"><span>Last Name</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div></div></div><div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  "><div class="super-label super-bottom-margin">Phone Number</div><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="tel" name="phonenumber" data-oname="phonenumber" data-validation="phone" data-email="Phonenumber:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Phone Number " data-placeholderFilled="Phonenumber"><span>Phone Number </span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  "><div class="super-label super-bottom-margin">E-mail</div><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="email" name="email" data-oname="email" data-validation="email" data-email="E-mail RCN:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="E-mail" data-placeholderFilled="E-mail Address"><span>E-mail</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  "><div class="super-label super-bottom-margin">Name of Prescribing Physician </div><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="Name_of_Prescribing_Physician" data-oname="Name_of_Prescribing_Physician" data-email="Name of Prescribing Physician " data-absolute-default="" data-default-value="" /></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  "><div class="super-label super-bottom-margin">Dr. Phone number</div><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="tel" name="phonenumber_dr" data-oname="phonenumber_dr" data-validation="phone" data-email="DrPhonenumber:" data-absolute-default="" data-default-value="" /></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-dropdown super-has-only-label   super-ungrouped  "><div class="super-label super-bottom-margin">Hours available for ABA services (*10 hour minimum required):</div><div class="super-field-wrapper "><input type="hidden" class="super-shortcode-field" name="hours_aviable" value="" data-oname="hours_aviable" data-email="Hours available for ABA services (*10 hour minimum required):" data-absolute-default="" data-default-value="" /><input tabindex="-1" type="text" name="super-dropdown-search" value="" data-logic="contains" /><ul class="super-dropdown-list"><li data-value="" class="super-item super-placeholder">- select an option -</li><li class="super-item" data-value="Morning " data-search-value="Morning "><div>Morning </div></li><li class="super-item" data-value="4PM-7PM" data-search-value="4PM-7PM"><div>4PM-7PM</div></li><li class="super-item" data-value=" Weekend flexible" data-search-value=" Weekend flexible"><div> Weekend flexible</div></li><li class="super-item" data-value="Afternoon (11-3)" data-search-value="Afternoon (11-3)"><div>Afternoon (11-3)</div></li><li class="super-item" data-value="After 7PM" data-search-value="After 7PM"><div>After 7PM</div></li><li class="super-item" data-value="Other" data-search-value="Other"><div>Other</div></li></ul><span class="super-dropdown-arrow"><span class="super-after"><i class="fas fa-caret-down"></i></span></span><span class="super-adaptive-placeholder" data-placeholder="- select an option -" data-placeholderFilled="- select an option -"><span>- select an option -</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped   super-conditional-hidden" data-conditional-action="show" data-conditional-trigger="all"><div class="super-label super-bottom-margin">Other</div><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="otherHoursaviable" data-oname="otherHoursaviable" data-email="otherHoursaviable:" data-absolute-default="" data-default-value="" /></div><textarea class="super-conditional-logic" data-fields="{hours_aviable}">[{"field":"hours_aviable","logic":"equal","value":"Other","and_method":"","field_and":"","logic_and":"","value_and":""}]</textarea><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-checkbox super-has-only-label   super-ungrouped   display-vertical"><div class="super-label super-bottom-margin">Days Requesting Services (*4 days a week required)</div><div class="super-field-wrapper "><div class="super-items-list"><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value="monday" /><div>Monday</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value="Tuesday" /><div>Tuesday</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value="Wednesday" /><div>Wednesday</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value="Thursday" /><div>Thursday</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value=" Friday" /><div> Friday</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value="Saturday" /><div>Saturday</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="checkbox" value="Sunday" /><div>Sunday</div></label></div><input class="super-shortcode-field" type="hidden" name="days" value="" data-oname="days" data-validation="empty" data-email="Days Requesting Services (*4 days a week required):" data-absolute-default="" data-default-value="" data-admin-email-value="both" data-confirm-email-value="both" data-contact-entry-value="both" /></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-radio super-has-only-label   super-ungrouped   display-vertical"><div class="super-label super-bottom-margin">Referred by (allow us to thank them) </div><div class="super-field-wrapper "><div class="super-items-list"><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="Physician" /><div>Physician</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value=" Google/Internet Search" /><div> Google/Internet Search</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="Friend" /><div>Friend</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="Esti/ Intake Coordinator" /><div>Esti/ Intake Coordinator</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="other" /><div>Other</div></label></div><input class="super-shortcode-field" type="hidden" name="Referredfield" value="" data-oname="Referredfield" data-email="Referred by (allow us to thank them) :" data-absolute-default="" data-default-value="" /></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped   super-conditional-hidden" data-conditional-action="show" data-conditional-trigger="all"><div class="super-label super-bottom-margin">Other</div><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="otherreferred" data-oname="otherreferred" data-email="otherreferred" data-absolute-default="" data-default-value="" /></div><textarea class="super-conditional-logic" data-fields="{Referredfield}">[{"field":"{Referredfield}","logic":"equal","value":"other","and_method":"","field_and":"","logic_and":"","value_and":""}]</textarea><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-textarea super-has-only-label   super-ungrouped  "><div class="super-label super-bottom-margin">Additional Comments</div><div class="super-field-wrapper "><textarea tabindex="-1" class="super-shortcode-field" name="Additional_Comments" data-oname="Additional_Comments" data-email="Additional Comments:" data-absolute-default="" data-default-value="" ></textarea><span class="super-adaptive-placeholder" data-placeholder="Please provide us with any relevant information that may be important" data-placeholderFilled="Question"><span>Please provide us with any relevant information that may be important</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div style="padding-top:20px;padding-bottom:20px;" class="super-shortcode super-field super-divider  super-align-left  super-ungrouped   align-left border-single style-dashed back-0"><div class="super-divider-inner" style="width:100%;border-color:#444444;border-top-width:1px;border-bottom-width:1px;height:1px;"></div></div><div class="super-shortcode super-field super-heading   super-ungrouped  "><div class="super-heading-title"><h1>Parent(s)/Legal Guardian Information</h1></div></div><div class="super-shortcode super-field super-heading   super-ungrouped  "><div class="super-heading-title"><h4>Caregiver Name</h4></div></div><div class="super-grid super-shortcode"><div class="super-shortcode super_one_half super-column grid-level-0 column-number-1 first-column "><div class="super-shortcode super-field super-text   super-ungrouped  "><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="first_namec" data-oname="first_namec" data-validation="empty" data-email="First Name C:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="First Name" data-placeholderFilled="First Name"><span>First Name</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div></div><div class="super-shortcode super_one_half super-column grid-level-0 column-number-2  "><div class="super-shortcode super-field super-text   super-ungrouped  "><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="last_nameC" data-oname="last_nameC" data-validation="empty" data-email="Last Name C:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Last Name" data-placeholderFilled="Last Name"><span>Last Name</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div></div></div><div class="super-shortcode super-field super-text   super-ungrouped  "><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="tel" name="phonenumber_c" data-oname="phonenumber_c" data-validation="phone" data-email="PhonenumbeCr:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Phone Number" data-placeholderFilled="Phonenumber"><span>Phone Number</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-shortcode super-field super-text   super-ungrouped  "><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="email" name="email_c" data-oname="email_c" data-validation="email" data-email="Email addressC:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="E-mail Address" data-placeholderFilled="E-mail Address"><span>E-mail Address</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div style="padding-top:20px;padding-bottom:20px;" class="super-shortcode super-field super-divider  super-align-left  super-ungrouped   align-left border-single style-dashed back-0"><div class="super-divider-inner" style="width:100%;border-color:#444444;border-top-width:1px;border-bottom-width:1px;height:1px;"></div></div><div class="super-shortcode super-field super-heading   super-ungrouped  "><div class="super-heading-title"><h1>Insurance Information</h1></div></div><div style="padding-top:20px;padding-bottom:20px;" class="super-shortcode super-field super-divider  super-align-left  super-ungrouped   align-left border-single style-dashed back-0"><div class="super-divider-inner" style="width:100%;border-color:#444444;border-top-width:1px;border-bottom-width:1px;height:1px;"></div></div><div class="super-shortcode super-field super-text super-has-only-label   super-ungrouped  "><div class="super-label super-bottom-margin">Primary Policyholder Name: </div><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="Primary_Policyholder_Name" data-oname="Primary_Policyholder_Name" data-email="Primary Policyholder Name:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Primary Policyholder Name: " data-placeholderFilled="Name"><span>Primary Policyholder Name: </span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div><div class="super-grid super-shortcode"><div class="super-shortcode super_one_half super-column grid-level-0 column-number-1 first-column "><div class="super-shortcode super-field super-radio super-has-only-label   super-ungrouped   display-vertical"><div class="super-label super-bottom-margin">Relationship to Student</div><div class="super-field-wrapper "><div class="super-items-list"><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="Mother" /><div>Mother</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="Father" /><div>Father</div></label><label class="super-item" ><span class="super-before"><span class="super-after"></span></span><input type="radio" value="Self" /><div>Self</div></label></div><input class="super-shortcode-field" type="hidden" name="relation" value="" data-oname="relation" data-email="Relationship to Student:" data-absolute-default="" data-default-value="" /></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div></div><div class="super-shortcode super_one_half super-column grid-level-0 column-number-2  "><div class="super-shortcode super-field super-text   super-ungrouped  "><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field" type="text" name="otherrs" data-oname="otherrs" data-email="Relationship to Student Other:" data-absolute-default="" data-default-value="" /><span class="super-adaptive-placeholder" data-placeholder="Other" data-placeholderFilled="Name"><span>Other</span></span></div><div class="super-error-msg">¡Se requiere campo!</div><div class="super-empty-error-msg">¡Se requiere campo!</div></div></div></div><div class="super-shortcode super-field super-date super-has-only-label   super-ungrouped  "><div class="super-label super-bottom-margin">Policyholder DOB</div><div class="super-field-wrapper "><input tabindex="-1" class="super-shortcode-field super-datepicker" type="text" autocomplete="false"  value="" 
        name="Policyholder_DOB" 
        data-format="dd-mm-yy" 
        data-jsformat="dd-MM-yyyy" 
        data-connected-min="" 
        data-connected-min-days="1" 
        data-connected-max="" 
        data-connected-max-days="1" 
        data-range="-100:+5" 
        data-first-day="1"
        data-localization=""
        data-change-month="true"
        data-change-year="true"
        data-show-month-after-year=""
        data-show-week=""
        data-number-of-months="1"
        data-show-other-months=""
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<p>La entrada <a href="https://leadersabatherapy.com/service/supervision-by-board-certified-behavior-analyst-bcbas-for-bcabas-and-rbts/">SUPERVISION BY BOARD CERTIFIED BEHAVIOR ANALYST (BCBA) FOR BCBA´S AND RBT.</a> se publicó primero en <a href="https://leadersabatherapy.com">Leaders Behavior ABA &amp; Counseling, LLC</a>.</p>
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