Kaleidoscope Program Application

Date_of_Birth*

Gender*

Female

Male

Unknown

Is our applicant currently enrolled in Kindergarten or a Head Start program?*

Address*

Address 2

Apt., Suite, etc.

City*

State*

Select

Zip Code*

First_Name*

Last_Name*

First Name *

Last Name*

In order for us to contact you about our wonderful programs and updates, can you provide us with your primary phone number?*

Phone

A backup number is always recommended incase we really need to reach you. Would you happen to have an alternative phone number?

Phone

When you just don't feel like answering your phone or your in a meeting at work, your email can always suffice! Please provide a valid email address for additional communication options.*

Secondary Email

Primary Physician*

Physician Phone Number*

Phone

Physician Office Location*

Other:

Insurance Number*

Was our new applicant diagnosed with Autism?*

Yes

No

Diagnosis_Date*

Please attach a copy of the most recent diagnostic evaluation report.*

Drag and drop files here or

If testing has not been administered, we can assist with obtaining testing for a diagnosis.*

Would_Like_To_Set_Up_Testing

Would_Not_Like_Testing

Testing_Scheduled_With_Provider

Testing_Done_With_Autism_Center_For_Enrichment

Has your child received services with us before?*

Yes

No

Specialty Program*

In-House Speech and Occupational Therapy are also included with your ABA Services. Your child will be evaluated upon enrollment for both included services.

Kaleidoscope Program- Fayetteville

Kaleidoscope Program- Greensboro

Kaleidoscope Program- Pinehurst

Referral Source Name (If Applicable)

Additional Comments

Thank You For Your Submission!

A representative will contact you shortly to go over the criteria for enrollment.

We look forward to speaking with you!

Thank You Tor Your Application!

Thank you for taking the time to complete our Kaleidoscope Program Application with us. A representative will contact you once we have reviewed your information.

If you need assistance, please call 910-295-2609.