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Name of Child
First Name *
Last Name *
Age of Child (Required)
Address
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
Parent/Guardian
First Name *
Last Name *
Phone (Required)
Email (Required)
Looking for Therapist(s)
PT
ST
OT
Feeding
Funding Source
Private Pay
ESA
DDD/ALTCS
Private Insurance (We are Out of Network with ALL Insurance companies)
Is your child approved for DDD & ALTCS Services
Yes
No
My Child has received previous therapy
Yes
No
Preferred Day/Time for appointment (Unfortunately ALL after school 3pm or later ST/OT/PT appointments are unavailable) (Required)
Preferred Location? Clinic? Home? If Home list your crossroads (Required)
What days does your child attend School? School Start and End Time? (Required)
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DDD Support Coordinator Name/Direct Phone/Email (Required)
Primary Pediatrician/Physician Name and Office Location (Required)
Name of Private Insurance (We are an Out Of Network Provider with ALL Insurances-may go towards deductible depending on coverage if eligible) (Required)
Name of DDD/ALTCS/AHCCCS Insurance (We do not accept AHCCCS unless your child is ALTCS approved) (Required)
Please list previous therapy(s), and location of therapy(s) received (Required)
Tell us a little bit about your child. How does your child communicate? What does their behavior look like on a bad day? (Required)
Any additional information you may want to add (Required)