-Lounge Application Form Pop-Up – REVEL

REVEL Programs Application

Client Name *

First

Last

Email *

Phone *

Client Address

Address Line 1

City

State

Zip Code

Client Date of Birth *

School Name and Grade (if applicable)

Client Diagnosis

Client Interests

Client Strengths

Client Challenges/ Areas for Growth

Funding Sources

Private Pay
Medicaid Waiver
Mill Levy

Reason why you are contacting us *

Individual Behavior Services
Attend the Lounge
Peer Mentor
Other

How would you like us to contact you? *

Phone
Email

Anything else you want us to know?