Origin
Caregiver's Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Email
Child's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Primary Insurance
*
Please Select
Blue Cross Blue Shield
Magellan
Aetna
Cigna
United Healthcare
None of the above
We are NOT currently in-network with Medicaid; however, we are actively working toward becoming an in-network provider.
Has your child been diagnosed with autism by a medical provider?
*
Yes
No
What area are you enrolling in?
*
Denton TX
Southlake TX
Sherman TX
How did you hear about us?
Please Select
Google
Facebook
Yelp
Print Ads
Insurance Company
Healthcare Provider
Event Booth
Word of Mouth
Facebook Group
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