Holland Center

Please complete the following information to begin the enrollment application process or to find out if Holland Center will be a good fit for your child. This is a secure form.
Child's Full Name
Date of Birth

MonthDayYear
Gender
Current Treatment Location
Primary Language
Secondary Language
Guardian Information
Guardian Name(s)
Marital Status
Home Phone #
Work Phone #
Cell Phone #
Email Address:
Email Address 2
Mailing Address
City
State
Zip Code
Primary Insurance Company
Policy Holder's Name
Policy Holder's Birth Date

MonthDayYear
Group Number
ID Number
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Child Description, Education History
Briefly Describe your Child.
Please describer your child's past and current treatment history. Include intensive behavior therapy, speech therapy, occupational therapy, music therapy, etc...
If you have supporting documents, you can attach them to this application. You may also email or mail us any supporting documents.
Upload Any Supporting Documents

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Does your child attend a School Program?
Please list your child's school diagnosis.
Please list your child's medical diagnosis.
Schedule Request
Please fill out the hours/days your child will be available for the session(s) and days you prefer. Note: this schedule will ultimately be determined by need (staff availability, child's clinical need based on assesment, etc...)
Monday
Tuesday
Wednesday
Thursday
Friday
Enter the words in the box before submitting your form.
Thank you for applying to enroll your child at Holland Center. Just hit "Submit" and we'll get back to you soon.
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Guardian Information

Request More Information or a Tour

Child Description, Education History

Schedule Request