Easing Your Journey

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Client Information

Client Full Name *

Date of birth *

Gender

male

female

Insurance Name *

Insurance Number *

Medicaid Number *

Address *

Street Address

City

Postal Code

Known Medical Conditions *

Allergies / Food Restrictions *

Guardian Information

Guardian Full Name *

Address (optional, if different from client’s address)

Relation to Client *

Phone *

Email *

Other Guardian Full Name

Other Guardian Relation to Client

Other Guardian Phone

Other Guardian Email

Emergency Contacts Information

School Information

School / Daycare / Group Home Name

School Address

School Phone

Physician Full Name

Physician Office Address

Physician Office Name

Physician Email

Physician Phone

Physician Fax

Transportation

Pickup Type

Specify Other:

Pickup Name

Pickup Address

Drop-off Type

Drop-off Name

Drop-off Address

Therapy Schedule

Therapy Type

Speech Therapy (ST)

Occupational Therapy (OT))

Physical Therapy (PT)

Behavior Therapy (ABA)

Which therapies will the client receive?

☑ Speech Therapy Monday

(Speech Therapy Monday) From

(Speech Therapy Monday) To

☑ Speech Therapy Tuesday

(Speech Therapy Tuesday) From

(Speech Therapy Tuesday) To

☑ Speech Therapy Wednesday

(Speech Therapy Wednesday) From

(Speech Therapy Wednesday) To

☑ Speech Therapy Thursday

(Speech Therapy Thursday) From

(Speech Therapy Thursday) To

☑ Speech Therapy Friday

(Speech Therapy Friday) From

(Speech Therapy Friday) To

☑ Speech Therapy Saturday

(Speech Therapy Saturday) From

(Speech Therapy Saturday) To

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Testimonials

"I’ve always been a little hesitant about using child care services, but after an unexpected work emergency, I’m so glad I had care arranged. The process was smooth, and the staff was incredibly kind and professional. It gave me peace of mind knowing my child was safe and happy."

John D

"Leaving your child with someone else can be stressful, but knowing there was trusted care available really helped me feel at ease. I had a last-minute situation, and the team was responsive, understanding, and supportive. I’ll definitely use this service again when I need child care in the future."