Parent Name
Phone Number
*
Email
*
Child's Name
Child Age
Birthday
Program
ABA
Social Skills
Both
Summer Camp
Discovery Day RSVP
Other
Insurance provider (Ask about the specific Medicaid Plans we accept)
Does your child have a Medical ASD Diagnosis?
[Diagnosis provided from school would not be accepted for our services. A Medical ASD Diagnosis is only provided by a Psychologist, Developmental Pediatrician, or a Neurologist.]
yes
No
N/A
other
How did you hear about us?
Facebook
Instagram
Referred by a community partner (BEST, NTX, P.E.A.R.S, LifeSpan, McKinney NueroPsych)
From a friend
Google Sponsored Ad
Internet Search
Met us at a community event.
Other
Specific Concerns or Notes for us to know.