Application for Enrollment

If you are interested in initiating FirstSteps services, please submit this application form, or simply contact our clinic at 1.800.819.FSFK. After receiving your information, an Intake Coordinator will be in touch to discuss our availability to meet your child's unique needs. We look forward to hearing from you!

Your Child

Please enter the child's name.
Invalid Input
Please select the child's gender.

Contact Information

Please enter the mother's name.
Please enter the father's name.
Please enter an address.
Invalid Input
Please enter a city
Please select a state
Please enter a zip code
Please enter a home phone number.
Invalid Input
Invalid Input
Please enter a valid email address.
Please select a service area.

Health Insurance

Diagnostic Information

School and Treatment History

Has your child received any specialized services to date?

ABA
Speech
OT
Other
Other

Invalid Input

Your Child

Services of Interest

Services






Desired Frequency

Your Availability

Are you open to being flexible if required to achieve a full schedule? *  

Please select an option
Preferred Times Unavailable Times Comments
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Family Goals