Client Waiting List Application

2026 NOTICE: We are currently accepting enrollment applications for children ages eighteen months to four years old.

"*" indicates required fields

First Name*

Client First Name

Last Name*

Client Last Name

Gender*

Birthdate*

How Did You Hear About Us?*

Who evaluated and diagnosed your child?*

Health Insurance Carrier*

Primary Policy Holder's DOB*

If you are planning to bill insurance, please provide the policy holder's DOB. This is required.

Parent/Guardian First Name*

Parent/Guardian Last Name*

Home Address

Street Address City State ZIP Code

Main Contact Phone:*

Email*

Preferred Method of Communication*

Email permissions*

Diagnostic Report*

Max. file size: 128 MB.

Please upload the full electronic copy of your child's diagnostic report. This is a required document for enrollment.

Primary Insurance (Photo of FRONT)

Max. file size: 128 MB.

Please use this option to upload a photo of the FRONT of your insurance card.

Primary Insurance Card (Photo of BACK)

Max. file size: 128 MB.

Please use this option to upload a photo of the BACK of your insurance card.