Tell Us About Your Family

1
How Many Kids are Ready for Therapy?* This field is required.
1 Kid
2 Kids
3 Kids
2
Where do You Live?
San Antonio, TX
Boerne, TX
3
Which language(s) do you prefer for therapy?
English
Spanish
English and Spanish
4
Child's First Name
5
Second Child's First Name
6
Third Child's First Name
7
How Old is {childsFirst}
Under 1 Year Old
1 Year Old
2 Years Old
3 Years Old
4 Years Old
5 Years Old
6 Years Old
7 Years Old
8 Years Old
9 Years Old
10 Years Old
11 Years Old
12 Years Old
13 Years Old
14 Years Old
15 Years Old
16 Years Old
17 Years Old
18 Years Old
19 Years Old
20 Years Old
8
How Old is {secondChilds}
Under 1 Year Old
1 Year Old
2 Years Old
3 Years Old
4 Years Old
5 Years Old
6 Years Old
7 Years Old
8 Years Old
9 Years Old
10 Years Old
11 Years Old
12 Years Old
13 Years Old
14 Years Old
15 Years Old
16 Years Old
17 Years Old
18 Years Old
19 Years Old
20 Years Old
9
How Old is {thirdChilds}
Under 1 Year Old
1 Year Old
2 Years Old
3 Years Old
4 Years Old
5 Years Old
6 Years Old
7 Years Old
8 Years Old
9 Years Old
10 Years Old
11 Years Old
12 Years Old
13 Years Old
14 Years Old
15 Years Old
16 Years Old
17 Years Old
18 Years Old
19 Years Old
20 Years Old
10
Which Therapies Does {childsFirst} Need?select all that apply
Occupational Therapy
Speech Therapy
ABA Therapy
Physical Therapy
Psychotherapy and Counseling
11
Which Therapies Does {secondChilds} Need?select all that apply
Occupational Therapy
Speech Therapy
ABA Therapy
Physical Therapy
Psychotherapy and Counseling
12
Which Therapies Does {thirdChilds} Need?select all that apply
Occupational Therapy
Speech Therapy
ABA Therapy
Physical Therapy
Psychotherapy and Counseling
13
Does {childsFirst} have a diagnosis?
YESNO
14
Does {secondChilds} have a diagnosis?
YESNO
15
Does {thirdChilds} have a diagnosis?
YESNO
16
What diagnosis does {childsFirst} have?select all that apply
ADHD
Anxiety
Apraxia
Autism
Cerebral Palsy
Cleft Lip/Palate
Depression
Developmental Delays
Down Syndrome
Dysphagia
Epilepsy
Obsessive-Compulsive Disorder (OCD)
Oppositional Defiant Disorder (ODD)
Sensory Processing
Speech and Language Disorders
Other
17
What diagnosis does {secondChilds} have?select all that apply
ADHD
Anxiety
Apraxia
Autism
Cerebral Palsy
Cleft Lip/Palate
Depression
Developmental Delays
Down Syndrome
Dysphagia
Epilepsy
Obsessive-Compulsive Disorder (OCD)
Oppositional Defiant Disorder (ODD)
Sensory Processing
Speech and Language Disorders
Other
18
What diagnosis does {thirdChilds} have?select all that apply
ADHD
Anxiety
Apraxia
Autism
Cerebral Palsy
Cleft Lip/Palate
Depression
Developmental Delays
Down Syndrome
Dysphagia
Epilepsy
Obsessive-Compulsive Disorder (OCD)
Oppositional Defiant Disorder (ODD)
Sensory Processing
Speech and Language Disorders
Other
19
Are you seeking a new diagnosis for {childsFirst}?
YESNO
20
Are you seeking a new diagnosis for {secondChilds}?
YESNO
21
Are you seeking a new diagnosis for {thirdChilds}?
YESNO
22
What diagnosis would you like to explore for {childsFirst}?select all that apply
ADHD
Anxiety
Autism
Depression
Developmental Delays
Obsessive-Compulsive Disorder (OCD)
Oppositional Defiant Disorder (ODD)
Sensory Processing
Speech and Language Disorders
Other
23
What diagnosis would you like to explore for {secondChilds}?select all that apply
ADHD
Anxiety
Autism
Depression
Developmental Delays
Obsessive-Compulsive Disorder (OCD)
Oppositional Defiant Disorder (ODD)
Sensory Processing
Speech and Language Disorders
Other
24
What diagnosis would you like to explore for {thirdChilds}?select all that apply
ADHD
Anxiety
Autism
Depression
Developmental Delays
Obsessive-Compulsive Disorder (OCD)
Oppositional Defiant Disorder (ODD)
Sensory Processing
Speech and Language Disorders
Other
25
{childsFirst} needs support to grow in these areas:
Communication and Language
Social Skills
Sensory Processing
Feeding and Eating
Fine Motor
Gross Motor
Emotional Regulation
Cognition and Learning
Self-Care and Independence
Attention and Executive Functioning
26
{secondChilds} needs support to grow in these areas:
Communication and Language
Social Skills
Sensory Processing
Feeding and Eating
Fine Motor
Gross Motor
Emotional Regulation
Cognition and Learning
Self-Care and Independence
Attention and Executive Functioning
27
{thirdChilds} needs support to grow in these areas:
Communication and Language
Social Skills
Sensory Processing
Feeding and Eating
Fine Motor
Gross Motor
Emotional Regulation
Cognition and Learning
Self-Care and Independence
Attention and Executive Functioning
28
Where would you prefer {childsFirst}'s therapy to take place?Choose all the places that work for you
At Home
In a Therapy Clinic
At an ABA Clinic
At Daycare
At a Private School
Online / Virtual Sessions
Other Location NOT Home
29
Where would you prefer {secondChilds}'s therapy to take place?Choose all the places that work for you
At Home
In a Therapy Clinic
At an ABA Clinic
At Daycare
At a Private School
Online / Virtual Sessions
Other Location NOT Home
30
Where would you prefer {thirdChilds}'s therapy to take place?Choose all the places that work for you
At Home
In a Therapy Clinic
At an ABA Clinic
At Daycare
At a Private School
Online / Virtual Sessions
Other Location NOT Home
31
Which days are best for {childsFirst}'s therapy?
Monday
Tuesday
Wednesday
Thursday
Friday
32
Which days are best for {childsFirst}'s and {secondChilds}'s therapy?
Monday
Tuesday
Wednesday
Thursday
Friday
33
Which days are best for {childsFirst}'s, {secondChilds}'s and {thirdChilds}'s therapy?
Monday
Tuesday
Wednesday
Thursday
Friday
34
Which times are most convenient for therapy?Select all that apply
8:00 AM - 9:00 AM
9:00 AM - 10:00 AM
10:00 AM - 11:00 AM
11:00 AM - 12:00 PM
12:00 PM - 1:00 PM
1:00 PM - 2:00 PM
2:00 PM - 3:00 PM
3:00 PM - 4:00 PM
4:00 PM - 5:00 PM
5:00 PM - 6:00 PM
35
What's your primary insurance provider?
Aetna
Anthem - Blue Cross Blue Shield
Blue Cross Blue Shield-Texas
Cigna
Community First
Humana
Medicaid
Oscar
Superior
Tricare
United Healthcare
Other
36
What's your primary insurance plan type?
PPO (Preferred Provider Organization)
HMO (Health Maintenance Organization)
EPO (Exclusive Provider Organization)
POS (Point of Service)
HDHP (High Deductible Health Plan)
Medicaid
CHIP (Children's Health Insurance Program)
Other
I'm not sure
37
I have a secondary insurance
YESNO
38
What's your secondary insurance provider?
Aetna
Anthem - Blue Cross Blue Shield
Blue Cross Blue Shield - Texas
Cigna
Community First
Humana
Medicaid
Oscar
Superior
Tricare
United Healthcare
Other
39
What's your secondary insurance plan type?
PPO (Preferred Provider Organization)
HMO (Health Maintenance Organization)
EPO (Exclusive Provider Organization)
POS (Point of Service)
HDHP (High Deductible Health Plan)
Medicaid
CHIP (Children's Health Insurance Program)
Other
I'm not sure
40
Caregiver's Name * This field is required.
First Name
Last Name
41
Email* This field is required.
example@example.com
42
Phone Number* This field is required.
Please enter a valid phone number.
43
What’s your current zip code?* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
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