Self Enrollment

Family or Child Needing Assistance

Please fill this form out in its entirety. Thank you!

Name*

First Last

Child's Name*

First Last

Child's Date of Birth*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Diagnosis*

Or suspicion of a diagnosis.

Primary Care Physician/Referral Soure*

If you don't have a PCP, enter NONE.

Which program are you most interested in?*

Choose the program that you would like to meet with first.

Upload Documents

The following documents are not required, however if you feel it will help us understand your needs, please upload the following if available. - Copy of diagnosis (medical record; Admission, Review and Dismissal (ARD); Individualized Education Program (IEP)

Drop files here or

Max. file size: 128 MB.

Comments

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Enrollment Form - Self

Family or Child Needing Assistance

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