Waitlist Form

1

Please verify that you are human* This field is required.

2

Name of contact person* This field is required.

First Name

Last Name

3

Contact person's email* This field is required.

example@example.com

4

Contact person's phone number* This field is required.

Area Code

Phone Number

6

Attach a picture of the front of insurance card* This field is required.Please verify that picture is legible before submitting.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

7

Attach a picture of the back of insurance card* This field is required.Please verify that picture is legible before submitting.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

8

I am interested in...* This field is required.

Occupational Therapy (OT)

Speech Therapy

Both OT & Speech

Unsure

9

The patient is...* This field is required.

a dependent on the insurance plan

the primary member of the insurance plan

10

Full name of the primary member on the insurance plan

First Name

Last Name

11

Primary member's date of birth

Date

12

Patient's full name* This field is required.

First Name

Last Name

13

Patient's date of birth* This field is required.

Date

14

Is the patient enrolled for services at a local Regional Center* This field is required.

Yes; Harbor Regional Center (HRC)

Yes; Westside Regional Center (WRC)

No