Child Intake Form - LSAC

Your Full Name*

First NameLast Name

Child's Full Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

What location are you interested in?

In-Home TherapyWestoverLeon Springs

How did you hear about us?*

Message

Do you consent to receiving text messages from Little Spurs Autism Centers at the phone number listed above?

YesNo

Marketing:
I authorize Little Spurs Autism Centers to send e-mails to my e-mail address indicated above for business purposes such as surveys, announcements, events, articles, links, general medical information and marketing material. I understand that I can opt out of the e-mail program at any time by following the instructions to 'opt out'.

Text Messaging:

By providing us with your wireless phone number, you consent to Little Spurs Autism Centers sending you informational text messages related to your child's therapy services. You can unsubscribe from text messages by replying STOP to any of these text messages. Messaging and data charges may apply to any text message you receive or send. Please contact your wireless carrier if you have questions about messaging or data charges. For Help, reply HELP

Email:

Health care providers using the Service may contact you via email to remind you of an appointment and to provide general health/medication/insurance reminders and information and you hereby agree to receive such messages via email. By consenting to receive any electronic information from Little Spurs via text message or email, you understand these methods of communication may not be secure and there may be some level of risk that the information in the email or text message could be read by a third party or be otherwise subject to unauthorized access or use. You are advised not to share personal health information via insecure text message or insecure email. Little Spurs is not responsible for unauthorized access of protected health information while in transmission to the individual based on the individual's request. Furthermore, Little Spurs is not responsible for safeguarding information once delivered. By agreeing to these terms, you agree to receive insecure text messages at your given phone number or any number forwarded or transferred to that number and to receive insecure emails. The consent to receive text messages or email will apply to all future appointment reminders/feedback/health/medication information and other communications unless you request us, as applicable, to stop sending the messages by replying "STOP" to a text message, unsubscribing from email, or other method designated by the health care provider or our Service. Please be aware that if you choose to stop receiving certain marketing emails or text messages, you may still receive certain important non-marketing messages related to your appointments. If you are not the intended recipient of any text messages or emails sent by Little Spurs, you are hereby notified that any review, dissemination, distribution, or duplication of this communication is strictly prohibited and you should promptly delete this information. Also, if you are not the intended recipient to text messages please reply "STOP" to any such text messages you receive. See Little Spurs Privacy Policy for More Information

Getting Started