Therapy Interest Form

Therapy Interest Form

Indie Learning Co. is an independent learning company that believes in nurturing the whole child in an immensely supportive learning environment. Our naturalistic approach to therapy ensures that sessions are person-centered, child-led and respective of communication and sensory needs. We are currently accepting new learners for naturalistic behavioral and speech therapy at our Central Phoenix location. We are proud to announce the roll out of occupational and physical therapy, beginning late Fall/Winter 2024. Fill out the below fields to the best of your ability and a member of our team will reach out to schedule an initial consultation!
Parent/Caregiver Information
Parent/Caregiver Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I'd like to receive more information via:*

EmailTextPhone Call
Child's Information
Child's Name*

First NameLast Name
Age*
Now accepting interest for Speech, Occupational and Physical therapy, to begin late Fall/Winter 2024 covered by plans under Arizona Health Care Cost Containment System (AHCCCS), Arizona Empowerment Scholarship Account (ESA), HSA and FSA.

NOTE: At this time, due to our approach, Naturalistic Behavioral Therapy will not be covered by insurance. We will continue to bill under ESA, HSA and FSA for this program.
I am interested in:*

In-center Naturalistic Behavioral TherapyIn-home Naturalistic Behavioral TherapyIn-center Speech Therapy (WAITLIST FOR AHCCCS)In-center Occupational Therapy (WAITLIST)In-center Physical Therapy (WAITLIST)
Is your child enrolled in the ESA program?*

YesAwaiting FundingNoI'd like more information on this program
Are you planning on using a plan under Arizona Health Care Cost Containment System (AHCCCS)?*

YesAwaiting approvalNoI'd like more information on this program
Anticipated Start Date*
month you anticipate your child beginning therapy services
Tell us anything that you'd like us to know about your child prior to our initial consultation!
Scheduling
List 3 preferred days/times for your initial consultation. We will follow up with an email to confirm.*
List 3 preferred days/times for your child's recurring therapy sessions. If we can accommodate these days/times, we will follow up with an email to confirm.*
As a company, we strive to eliminate the barriers to receiving exceptional, person-centered support, regardless of neurotype, background or diagnosis. This means that your child does NOT need a medical diagnosis to receive services from us. In our 45-minute consultation we will spend time listening and reviewing areas of support that are most important to your family.
Should be Empty:

Therapy Interest Form

Parent/Caregiver Information

Child's Information

Scheduling