VISITOR INFORMATION Date of First Contact Dale of Tour/Visiit Child's Full Name DOB Insurance: Member ID#: Parent/Guardian 1 Last Name First Name Phone Number: Email: Address: City: Zipcode: Parent/Guardian 2 Last Name First Name Phone Number: Email: Address: City: Zipcode: How did you hear about us?: When would you hear about us?: In what services are you interested? ABA Therapy School Occupational Therapy Check List Referral or physicians order for Behavior Assessment (Must include: client name, DOB, Dx/ICD10 Code, and Dr. Signature) Insurance Card Evaluation from Neuroligist and/or Psychiatrist Doctor´s Note Individualized Educational Plan (IEP) or Individualized Family Service Plans (IFSP), if applicable. NOTE: Admission process is estimated to take 2-4 weeks. NOTES: Submit
