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New Family Intake

Does your child have a secondary insurance policy under another parent?
Upload File
If yes, upload copy of that card (Pic front and back), secondary subscribers name/DOB.
Does your child have Medi-Cal or CalOptima coverage?
Insurance Card (Front)
Upload supported file (Max 15MB)
Insurance Card (Back)
Upload supported file (Max 15MB)

Known Diagnosis

Do you have a diagnostic or assessment report?
Upload File
If yes, upload diagnostic report.
Do you have a prescription?
Upload File
If yes, upload prescription.
Do you have IEP?
Upload File
If yes, upload here.
Do you have an insurance referral?
Upload File
If yes, upload referral here.

Thanks for submitting!

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