Apply for Admission

At our center, we are dedicated to providing personalized, evidence-based therapies in a caring and supportive environment. Our goal is to empower individuals and families to thrive in every aspect of life—at home, in the community, and beyond.

To begin the application process, please gather the following essential documents. These can be uploaded during the application or submitted later if needed:

Psychological Evaluation: A formal assessment confirming a diagnosis on the autism spectrum, conducted by a licensed psychologist or developmental pediatrician.
Interdisciplinary Team Annual Review: The most recent review document, such as an IEP (Individualized Education Plan), ISP (Individualized Service Plan), or IPP (Individual Program Plan).
SIS (Supports Intensity Score) Evaluation: Required for adult applicants only.
Medicaid and/or Insurance Information: Documentation to facilitate billing and coverage verification

Is the applicant currently receiving any services from Family Envision? yesno

What is your relationship to the applicant?

How did you hear about us?

Name of Case Manager

Are you the legal guardian? yesno

Guardian's relationship with applicant?

Preferred Language of Communication

Is there a second guardian?

Please select the type of services you're seeking.

How soon is the applicant seeking services?

Are there additional services you would like Family Envision to offer in the future? Tell us more. yesno

List all diagnoses. Applicant must have a diagnosis of autism spectrum disorder to receive services from Family Envision.

Does the applicant have any physical limitations? yesNo

Has the applicant had any seizures? yesno

Does the applicant take any prescription medication? yesno

Does the applicant have any allergies? yesno

How does the applicant communicate? Select all that apply

Where does the applicant need the most support

Please upload the applicant's psychological evaluation.

This evaluation must be conducted by a licensed psychologist or developmental pediatrician to determine a diagnosis on the autism spectrum. If you're applying for ABA services, it's incredibly important this documentation identifies which autism-specific assessment too was used, as well as the scores obtained, to determine the diagnosis. This requirement is needed in order for Family Envision to obtain necessary authorization to provide services to this individual in the future.

Please upload the applicant's Individual Service Plan, if applicable. .

The most recent interdisciplinary team plan might be an IEP, ISP, IPP, IFSP, etc

Please upload Primary Insurance Information .

A copy or picture of the insurance card.

Please select the type of other additional documentation you would like to provide.

Please upload the document.

Notes on additional documentation.

Do you have other documents you would like to this application?

I verify the information submitted is true and accurate to the best of my knowledge.

Apply for Admission

Apply for Admission

Referral Information

Guardian Information

Service Information

Current Agency Involvement

Medical Information

Please upload the applicant's psychological evaluation.

Please upload the applicant's Individual Service Plan, if applicable. .

Please upload Primary Insurance Information .

Additional Documentation 1

Admission Form

Links

Contact

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