Eligibility Check Form

1
Type of services needed* This field is required.DENALI OFFERS MANY SERVICES, PLEASE SELECT ONE
ABA Therapy (Behavior Therapy for my child)
Mental Health Services (for myself or my child)
Courses, Free training for parents.
2
Client’s Name (Person Receiving Services)* This field is required.
First Name
Last Name
3
Client’s Email or Caregiver* This field is required.
example@example.com
4
Client’s Phone Number or Caregiver* This field is required.
Please enter a valid phone number.
5
Date of Birth - Person receiving services
Date
Month
Day
Year
6
Insurance card of the person receiving services (front and back)This image will be deleted after 60 days
Drag and drop files here
Select files to upload
Browse Files
Cancelof
7
Would you like to be contacted bySelect one or more
Text
Phone call
Email
All
Should be Empty: