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Intake Form
Please complete this form and a staff member will contact you as soon as possible.
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Email
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Your email
Parent/Guardian's First Name:
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Your answer
Parent/Guardian's Last Name:
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Your answer
Child's First Name:
*
Your answer
Child's Last Name:
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Your answer
Child's Age:
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Primary Contact Number:
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Insurance Carrier:
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Blue Cross Blue Shield
Anthem
Cigna
Aetna
United Healthcare
Medicaid (We do not accept Medicaid)
CHIP (We do not accept CHIP)
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No Insurance
If you have another insurance carrier not listed above, please provide us with the name of the insurance.
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How did you hear about Autism Pediatric Therapy?
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Doctor Referral
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Location of Interest
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We currently have three locations in the Houston area. Please let us know at which location you would be interested in receiving services.
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Clear Lake
Pearland
Preferred Method of Contact:
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Phone Call
Text Message
Email
Does your child have an Autism diagnosis?
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Yes
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What are the primary concerns that you have for your child?
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