INTAKE | TLCBC

top of page

TLC BEHAVIORAL
CONSULTING AND SUPPORT LLC

HOME
ABOUT
INTAKE
- INTAKE PROCESS
CAREERS
RESOURCES
CONTACT
More

Use tab to navigate through the menu items.

The journey of a thousand miles begins with a single step.

Lao Tzu

Intake Form

Child's First Name

Last Name

Child's Date of Birth

Caregiver's Firs Name

Last Name

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

Code

Phone

Email

Preferred Method of Contact

Primary Care Provider

Has your child had ABA services before?

Please upload the FRONT of your insurance card.

Upload File

Upload supported file (Max 15MB)

Please upload the BACK of your insurance card.

Upload File

Upload supported file (Max 15MB)

Referral Source

Additional Info

Thanks for submitting! We will get back to you within 48 hours.

Copyright TLC Behavioral Consulting and Support LLC. 2023 | Website Created by Charlie O.

bottom of page