Request Services

To register, please take the time to fill out the information below.

Child's First Name

Child's Last Name

Child's DOB

Child's Age

Child's Gender

Diagnosis Assessment or Neuro/Psych Evaluation

Doctor's Perscription

Individualized Education Plan (IEP)

Parent Information

Parent/Legal Guardian First Name

Parent/Legal Guardian Last Name

Street Address

City

State

ZIP Code

Home Phone

Cell Phone

Marital Status

Driver's License Photo

How did you hear about us?

Parent/Legal Guardian 2 First Name

Parent/Legal Guardian 2 Last Name

Street Address

City

State

ZIP Code

Home Phone

Cell Phone

Marital Status

Driver's License Photo

Insurance Information

Primary Insured's Name

Policy Number

Group Number

Date Effective

DOB of Policy Holder

Front of Insurance Card

Back of Insurance Card

Secondary Insured's Name

Policy Number

Group Number

Date Effective

DOB of Policy Holder

Front of Insurance Card

Back of Insurance Card

Doctor Information

Doctor's Name

Doctor's Address

Phone

Fax