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.