ENROLLMENT Enroll Your Child Today! Please enable JavaScript in your browser to complete this form.Getting to Know the Client Who will be receiving our services Client Name *FirstLastGender *Select oneMaleFemaleNon-binaryDate of BirthReferred by *Diagnosis ReceivedAutismADD/ADHDOther Getting to Know the Family Parent/guardian information Parent/Guardian Name *FirstLastRelationship to Client *Marital Status *Select oneMarriedSingleDivorcedPrimary Email *Street AddressCityStateALALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPAPRRISCSDTNTXUTVTVAWAWVWIWYZip Code *Cell Phone *Home Phone *Preferred NumberCell PhoneHome PhoneBest Time to CallMorningAfternoonEveningThe Paperwork This is the last part! Please choose the best days and times for your appointments, and provide your funding information below. Appointment Scheduling Available Days of the WeekSundayMondayTuesdayWednesdayThursdayFridaySaturdayBest Appointment Time *Second Best Appointment Time *Insurance Information Take pictures of the front and back of your insurance card and upload them below. Funding Source *Select oneMedicaidBCBSCignaAetnaUnitedOtherUpload Front of Insurance Card Click or drag a file to this area to upload. Upload Back of Insurance Card Click or drag a file to this area to upload. Custom Captcha * = Submit
