Enrollment

Parent/Guardian Information

Full Name *

Phone Number

Email Address *

Relationship to Child*

Best Day/Time to Contact

Child Information

Child's Full Name *

Zip Code *

Confirmed Autism Diagnosis? *

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Preferred Service Location *

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Services Desired *

Select services▾

SpeechOTABAOther

Availability for Services *

Select days▾

MondayTuesdayWednesdayThursdayFriday

Scheduling Availability and Barriers

Please specify your availability and any scheduling barriers (e.g., school hours, therapy sessions). Include the specific hours available for each day selected above.

Insurance Information

Insurance Provider Name *

Insurance ID # *

Secondary Insurance?

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Secondary Insurance ID

File Upload — Diagnostic Report

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File Upload — Insurance Card (Front and Back)