Parent or Legal Guardian Name *

First Name

Last Name

Please Select Your Primary Insurance Company *

Select Health (Care, Choice, Med, Value, Share)

Select Health Community Care (Medicaid)

Molina Health Care

University of Utah Health Plans

Healthy U Medicaid

Blue Cross Blue Shield (We Do Not Accept Focal Point)

Utah State Medicaid

We would like to pay Cash/Are not in any of these networks

Services *

Please select which service(s) you are interested in for your child:

Occupational Therapy (OT)

Speech Therapy

CBIT for Tics or Tourette Syndrome