intake inquiry

No Contracts Required!
No Minimum Hours of Therapy Required!

If you are ready to move forward with therapy services, please complete the form below to get started with our intake process.

For any other questions, contact us here.

Your name(Required)

First Last

Email(Required)

Phone(Required)

Please select the closest location(Required)

*For Waitlist: Inquiries will be placed on our waitlist and you will receive notification once hours become available.

Please select your insurance carrier(Required)

Insurance provider(Required)

Child's name(Required)

First Last

Child's gender(Required)

Child's birthdate(Required)

Does your child have an Autism diagnosis? (If NO, please use our CONTACT US form to request autism testing.)(Required)

Please provide your child’s diagnosis.

How did you hear about us?(Required)

Which event?(Required)

Which doctor?(Required)

Other(Required)

How can we help?(Required)

Phone

This field is for validation purposes and should be left unchanged.

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