Enrollment Form | Always Keep Progressing

Welcome

We're happy to meet you! To get started, we need to register an account for your child and then get you scheduled. We accept new patients from birth to 21 years of age at all of our centers. Your information is secure with us, and we never share it without your permission.

Tell Us What Support You’re Looking For

Help us understand your child’s current needs, diagnosis status, and the types of therapy or evaluations you may be seeking.

Has your child been diagnosed with autism by a medical doctor or psychologist? *YesNo

Are you seeking a diagnostic evaluation to see if your child has autism? *YesNo

Are you seeking therapy services for any of the following: *Autism; ADHD; developmental delay (such as delays in speech, motor, or cognitive development); intellectual, cognitive, or learning disability; sensory processing disorder; cerebral palsy; genetic syndrome; or epilepsy.YesNo

Tell Us About Your Child

We’ll use this information to begin creating your child’s intake profile and match your family with the appropriate services and next steps.

First Name *

Last Name

Gender *

Date of Birth *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal code

Country

Parent & Caregiver Details

Please provide the primary contact and caregiver information for your child’s enrollment and ongoing communication.

Are you the patient's primary Caregiver? *YesNo

Are you the legal guardian? *YesNo

Are you the emergency contact? *YesNo

What is your relationship to the patient? *

Caregiver Details

First Name *

Last Name

Email Address

Phone

Address same as patientYes

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal code

Country

Insurance Verification & Availability

Share your insurance information and scheduling preferences so our team can help verify benefits and coordinate next steps.

Insurance Provider

Policy Holder Name

Best Days & Times for TherapySelect the days and time windows that usually work best for your family. This helps our scheduling team find the best available therapy options for your child.

Best Days

Best Time of Day