New patients

Start your child’s intake online.

Complete the patient information and case history forms below. Our team will review the full background and follow up about next steps.

What you will need

Gather these items before you begin.

01

Insurance card

Clear images of the front and back.

02

Parent ID

A copy of the insured parent's driver's license.

03

Provider details

Contact information for relevant doctors and dentists.

Step 1 of 5Patient

1Patient
2Parent
3Insurance
4Providers
5Documents & consent

Case History & Background Information

Help us understand the whole child.

Fields may be left blank only when they do not apply.

Step 1 of 11Child & school

1Child & school
2Family
3Development
4Supports
5Medical
6Life skills
7Safety
8Feeding
9Communication
10Concerns
11Complete

01Child and family history

Share birth, diagnosis, school, and support information.

Today’s dateChild’s full nameDate of birthAgeGenderDeliveryWeeks of gestation when bornPregnancy or delivery complications?If yes, explain the pregnancy or delivery complications

Current diagnoses List all separately

DiagnosisAge diagnosedDiagnosing physicianApproximate diagnosis date

DiagnosisAge diagnosedDiagnosing physicianApproximate date

DiagnosisAge diagnosedDiagnosing physicianApproximate date

DiagnosisAge diagnosedDiagnosing physicianApproximate date

DiagnosisAge diagnosedDiagnosing physicianApproximate date

School information

School child attendsGradeIs an IEP in place?Date of last IEP meetingClassroom typeDescribe special support received at schoolIEP documents from the last two yearsIf applicable, attach up to three PDF, JPG, or PNG files; 10 MB maximum per file.

06Academics and daily living

Describe current ability, independence, age consistency, and refusal for each skill.

Academics

Complete each item using the same categories requested on the paper form.

Read

Can do this skill?How is it completed?Consistent with age?Refuses?

Identify letters

Can do this skill?How is it completed?Consistent with age?Refuses?

Identify numbers

Can do this skill?How is it completed?Consistent with age?Refuses?

Cut

Can do this skill?How is it completed?Consistent with age?Refuses?

Sit for a story

Can do this skill?How is it completed?Consistent with age?Refuses?

Color

Can do this skill?How is it completed?Consistent with age?Refuses?

Write / color

Can do this skill?How is it completed?Consistent with age?Refuses?

Hold a crayon

Can do this skill?How is it completed?Consistent with age?Refuses?

Hold a pencil

Can do this skill?How is it completed?Consistent with age?Refuses?

Sit in a chair

Can do this skill?How is it completed?Consistent with age?Refuses?

Look when name is called

Can do this skill?How is it completed?Consistent with age?Refuses?

Activities of daily living

Complete each item using the same categories requested on the paper form.

Brush teeth

Can do this skill?How is it completed?Consistent with age?Refuses?

Wipe after toileting

Can do this skill?How is it completed?Consistent with age?Refuses?

Wash in the bath

Can do this skill?How is it completed?Consistent with age?Refuses?

Pick out clothes

Can do this skill?How is it completed?Consistent with age?Refuses?

Use a fork

Can do this skill?How is it completed?Consistent with age?Refuses?

Use a spoon

Can do this skill?How is it completed?Consistent with age?Refuses?

Drink from an open cup

Can do this skill?How is it completed?Consistent with age?Refuses?

Drink from a sippy cup

Can do this skill?How is it completed?Consistent with age?Refuses?

Dress

Can do this skill?How is it completed?Consistent with age?Refuses?

Undress

Can do this skill?How is it completed?Consistent with age?Refuses?

Tie shoes

Can do this skill?How is it completed?Consistent with age?Refuses?

Additional concerns related to daily living skills

09Play and communication development

Describe play, understanding, expressive communication, speech, and social interaction.

Play skills

Describe your child’s play skillsWhat is played with?Are toys played with for their intended purpose?

Who does your child play with?

Adults Children Alone

What does your child’s interaction look like when playing with other children?

Communication development

Scholarship resource

Step Up For Students

Explore Florida education scholarship programs for eligible families.

UnitedHealthcare Children's Foundation

Learn about medical grants for costs not fully covered by commercial insurance.