ENGLISH
(1) REGISTRATION FORM
(2) FINANCIAL CONSENT
(for children with insurances other than medicaid, and including children in the babies can't wait program)
(3) MEDICAID CONSENT
(for children with Medicaid insurance)
(4) TELEMEDICINE CONSENT
(5) PRIVACY POLICY
(6) PREVIOUS THERAPY DISCHARGE FORM
(for children who have been receiving this service elsewhere)
(7) MEDICAL RECORDS RELEASE FORM
(if you would like us to share our records with others)
En Español
In order to begin services to improve your child’s skills, please be prepared to provide:
• A prescription from your Primary Care Physician for the therapy your child will receive. You can call their referral line and ask them to fax this to us at 404-228-9293.
*** Due to the delays and limited staffing at doctors’ offices, please be sure to have your child’s prescription for therapy services ready before registering. We are not able to obtain this for you.
If you have questions or need help gathering these items please email us at [email protected]
Please fill out and submit the forms above.
Please fill out and sign every form in this sequence to avoid delays in registration. If a question or form is not applicable to your child, you can leave that part blank and move to the next step.
If your child has any type of medicaid, a photo of the medicaid card is not required but please include the “medicaid ID number”.
Click on each tab separately to access the corresponding form.
Thank you!