playABILITIES Client Intake Form Joshua Center for Neurological Disorders changing lives since 1996 Child's Name:* First Last Child's date of birth:* Contact/Caregiver Name:* First Last Contact Number:*Enter phone numberEmail:* Enter Email Confirm Email Home Address:* Street Address Address Line 2 City State / ProvinceAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary reason for seeking treatment:*Does your child have a current diagnosis?*Is your child currently receiving services or have they in the past?*Services I am seeking:* Occupational Therapy Speech Therapy I'm not sure We need a copy of your insurance card to get your coverage information. Please choose from the below:*I have texted a picture of both sides of my insurance card to 913.948.4223.I have emailed both sides of my insurance card to Therapy@playabilities.orgWe will be private pay.Secondary Insurance:*I have secondary insuranceI do not have a secondary insuranceHow did you hear about us?*NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle AJAX powered Gravity Forms.