Emerge Club Registration Form

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

 
 

(First, Last)

 
 
mm/dd/yyyy
 
 

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.
 
 
 
 

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

 
Phone
 

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

 
 
 
 
 
 
 

If yes, please list below:

 

 

Does your child...?

 
 
 
 
Drop your files here
 
 
 
 
 
 

 

Please specify which club

 
 

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

 
 
 

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.

 

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