For Services Provided Month
Location of Service
Name & Credential of Person Providing Services
Description of Service Provided
Signature of Parent or Legal Guardian
*This applies to the following Service Codes: 612-Behavior Analyst, 613-Associate Behavior Analyst, 615-Behavior Management Assistant, 616-Behavior Technician-Paraprofessional, 620-Behavior Management Consultant, 625-Counseling Services, 680-Tutor, 017-Crisis Team-Evaluation and Behavioral Intervention Training, 025-Tutor Services - Group, 048-Client/Parent Support Behavior Intervention Training, and 077-Parent-Coordinated Home Based Behavior Intervention Program for Autistic Children.
Instructions to the Parents or Legally Appointed Guardians: Please Sign, date, and submit this form to your vendor within 30 days from the time the services were provided. If you are unable to sign the form, please contact your regional center service coordinator/case manager as soon as possible.
If you have any questions, please feel free to contact your regional center service coordinator/case manager.
Name of Parent Legally Appointed Guardian
Parent or legally Appointed Guardian Signature
Main Office Northridge
8940 Reseda Blvd #102, Northridge
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