Registration Form

To begin our intake process, please complete the form below.

New Client Registration

Once your form is submitted, we will begin to verify your insurance benefits. We are not responsible for any incorrect information given to Spectacular Kids by the insurance company about your benefits. Verification of benefits does not guarantee coverage of services nor is Spectacular Kids responsible for how claims are processed by your insurance company.

Client Registration

Free Text

1. Client Information

Location of Interest*

First Name

Last Name

Middle Name

Date of Birth

Gender

Diagnosis

Who diagnosed your child?

How did you hear about us?

Free Text

2. Family Information

Free Text

Please provide complete contact info for at least one parent.

Primary's Name*

Primary Contact*

Free Text

**Our Intake Coordinator will contact you to solidify your date and time.**

Primary Contact(First Name)

Primary's Phone Number*

Primary's Email*

Address

Primary's City

Primary's State / Province

Primary's Postal / Zip Code

3. Services

Current Placement

Services Requested

In-Clinic ABA Therapy

Social Skills Group

Development/Behavioral Assessment

Occupational Therapy (Missouri City only)

Current Therapy Services

Speech Therapy

Occupational Therapy

Physical Therapy

Psychological Services

Other

4. Insurance Information

Health Insurance*

Insurance Company

Name of Policy Holder

Policy Holder DOB

Relationship to Client

Employer

Member ID

Group Number

Registration Form

New Client Registration

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