Parent Information

Parent's First Name

Parent's Last Name

Phone Number

Address

City

State

Zip

Your Email (required)

Patient Information

Child's First Name

Child's Last Name

Child's Date of Birth

What is your child's clinical diagnosis from their physician?

What is your child's secondary clinical diagnosis from their physician?

What is your primary insurance?

What is your secondary insurance (optional)?

What services does your child require?
ABAPTOTSLPMusicCounseling

What is your preferred method of contact?

Required Documents

These are the documents that are required during your intake meeting. A member of our team will be contacting you to schedule a meeting time:

1. Photo ID

2. Insurance card(s)

3. A physician referral for therapy services with the diagnosis.