Start Your Elevated Journey

Choose the option that best fits your needs

Schedule a Consultation

Complete Intake Form

Ready to move forward? Complete the intake form to begin the enrollment process

Child Information

Child's First Name

Child's Last Name

Date of Birth

Month

Day

Year

Gender (Optional)

Primary language spoken at home

Has your child been diagnosed with Autism Spectrum Disorder (ASD)?

Yes

Diagnoses in progress

Date of diagnosis

Diagnosing provider

Parent / Guardian Information

Parent/Guardian Full Name

Relationship to Child

Phone

Address

Guardian Government ID

Preferred Method of Contact

Secondary Guardian Name

Secondary Guardian Phone

Insurance Information

Does your child have active insurance coverage?

Primary Insurance Provider

Member ID / Policy Number

Secondary Insurance Provider (if applicable)

Insurance Customer Service Phone Number

Upload a copy of your insurance card (front and back)

Is your child enrolled in Georgia Medicaid?

Required Documents for Services

If available, please upload relevant documents to help us review eligibility and move forward with services. You may submit this form even if documents are not yet available; however, required documents must be provided prior to or at the time of the initial assessment.