Get Started with Meliora Health

Get Started with Meliora Health
Please select one of the following:*

I am a Parent/GuardianI am a Patient (Required if 18+)I am a Referring Provider
Patient Legal Name*

First NameMiddle Name(s)Last Name(s)Suffix
Patient Preferred First Name
Patient Date of Birth*

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Patient Age*
Patient Legal Sex*

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Your Legal Name*

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Relationship to Patient*

Biological ParentAdoptive/Foster ParentLegal GuardianStepparentOther
Phone Number*
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Email Address*
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Please select your state and PRIMARY insurance plan.*
Patient County*
Preferred Language*

EnglishSpanish
Reason(s) for Inquiry*

Autism Evaluation (16 months to 21 years)ADHD Evaluation (5 years to 21 years)ABA Order Visit (16 months to 21 years)¹Developmental Pediatrics (16 months to 21 years)^1,2,3Social Skills Support (16 months to 21 years)^1,3
How did you hear about us?*
Additional Information
Thank you for choosing Meliora Health, please follow this link to complete our provider referral form.
Today's Date*

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Meliora Health is only able to provide services for patients between 16 months and 21 years of age.
Meliora Health is only able to provide ADHD services for patients between 5 and 21 years of age. Please deselect ADHD Evaluation or update Patient Date of Birth.
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