Intake Form
Please complete this form and a staff member will contact you as soon as possible.
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Email *
Parent/Guardian's First Name: *
Parent/Guardian's Last Name: *
Child's First Name: *
Child's Last Name: *
Child's Age: *
Primary Contact Number: *
Insurance Carrier: *
If you have another insurance carrier not listed above, please provide us with the name of the insurance.
How did you hear about Autism Pediatric Therapy? *
Location of Interest *
We currently have three locations in the Houston area.  Please let us know at which location you would be interested in receiving services.
Preferred Method of Contact: *
Does your child have an Autism diagnosis? *
What are the primary concerns that you have for your child? *
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