Thank you for your interest in participating in intensive therapy at Family Achievement Center. Please take a moment to fill out this form to provide more information and we will contact you once it is received.
Client Name
*
First Name
Last Name
Parent/Caregiver Name
*
First Name
Last Name
Alternate Parent/Caregiver Name
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Client Date of Birth
*
-
Month
-
Day
Year
Date
Primary Diagnosis (if applicable)
Additional Diagnoses (if applicable)
Primary Insurance
Plan Name and Member ID
Secondary Insurance (if applicable)
Plan Name and Member ID
Is your child currently receiving therapy services at Family Achievement Center?
Yes
No
Received therapy services at FAC previously
Does your child receive therapy services elsewhere?
Yes
No
If yes, please tell us where they receive therapy services and what services they receive.
Intensive Therapy Clinic Location Preference
Woodbury
Bloomington
No clinic location preference
What are the main areas you would like your child to work on during their intensive at Family Achievement Center?
Additional questions or comments
Submit
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