Initial Intake Form

Student's First name

Student's Last name

Student's Date of Birth

Parent/Guardian Full Name (First, Last)

Email

Phone

Please select your program of interest (all that apply)

5-day program

3-day program

Afterschool Enrichment

Other

Therapeutic Services (ABA, OT,PT,ST)

My child's current provider/s can work with them on program site.

I would like to request services through myT.R.I.B.E's partner providers.

My child doesn't require additional services.

Additional Services Requested through partner providers

Are you open to using out-of-network services who can provide superbills for the services you choose?

Yes

No

Please name your insurance provider and carrier so we can work with our partners.

Please describe briefly , your goals and aspirations for your child?

myT.R.I.B.E