I would like to enroll my child now!

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If you would like us to reach out to you to schedule a time to begin the process of enrollment please complete the form below.

Please share the parent/guardian name. *

Please share the parent/guardian phone number. *

Please share the parent/guardian email. *

Our family is interested in (please check all that apply) *

School readiness

Saturday social group

Saturday therapy sessions

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How old is your child? *

1-3 years old

4 - 6 years old

7 - 9 years old

10 - 12 years old

older than 12

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Please tell us the insurance carrier you currently have. *

BCBS PPO

United Healhtcare

Aetna

Other:

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Please tell us the location you are interested in learning more about. *

Buffalo Grove

Vernon Hills

Lake in the Hills

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How did you hear about us? *

My child's physician

Friend

Internet search

Facebook

Other:

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This form was created inside of Roots Autism Solutions & Therapeutic Academy.