Emerge Club Registration Form

Emerge Club Registration Form

Please note that Emerge Clubs are private pay and will not billed through insurance.

What club are you interested in registering your child for?*

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Child's Name*

(First, Last)

Child's Date of Birth*

Child's Age*

Child's Pronouns

Emerge is an identify-affirming practice and a safe space. We ask for your child's pronouns so that we may address them in a way that feels comfortable for them and is identity-affirming.

If you would like to learn more about why we ask for pronouns, follow this link.
If you would like to read more about how using chosen names and pronouns can help reduce depression symptoms and suicidal ideation in teens, follow this link.

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Pronouns (not previously listed)

If you are a current Emerge client with one of our in-network insurance providers (NCMC, Tricare, etc.), check "yes" and our intake coordinator will reach out to you with more information.**

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Caregiver's Name*

Relationship to the child?*

Address*

Please include the street address, city, state, and zip code.

Phone*

Phone

By checking this box you agree to receive text messages from Emerge Pediatric Therapy related to scheduling. You can reply STOP to opt-out at any time. Reply HELP to 919-928-0204 for customer care or contact information. Messages and data rates may apply. Message frequency will vary. This is Emerge's privacy policy: https://emergepediatrictherapy.com/privacy-policy/.*

This opt in is for company communication regarding scheduling and care, not an opt-in for marketing materials.

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Email Address*

How did you hear about this club?*

Name of the Emerge staff member who referred you

What is your child's current school

Will your child be attending school in the fall?

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Grade

Does your child receive any additional services at school?

If yes, please list below:

Does your child...?

Attend therapy sessions at Emerge?

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Receive services elsewhere?

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If so, where? (Please attach a copy of a recent report.)

File Upload

Drag and drop files here or

Have any allergies?*

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If yes, please list:

List any dietary restrictions that your child has:

Currently or previously receive psychological services?

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If so, where?

I am interested in enrolling my child in a club program because...

Please specify which club

My child's strengths include:

My child demonstrates challenges regarding:

Please include any differences with sensory processing, communication, or social participation.

Strategies that help my child include:

List and diagnoses (formal or informal) that your child has:

Authorization for Child Pick-Up*

Please list the names and phone numbers of individuals who are authorized to pick your child up from therapy sessions at Emerge Pediatric Therapy. The staff at Emerge Pediatric Therapy will ask for a photo ID from anyone who is picking your child up from the clinic.

Send me a copy of my responses

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