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Child Information

MM/DD/YYYY

Sex assigned at birth*

Male

Female

Gender Pronoun*

He

She

They

If other, please specify:

Who is the Child's Pediatrician?*

Practice Name:*

What is their phone number?

To meet your child’s therapy needs as soon as possible, please provide all days & times you are available for evaluation and ongoing therapy sessions. Note: There is currently a waitlist for after–school appointments (3 PM – 7 PM), with preference being given to our current clients. If you’re looking for after-school appointments only, we strongly encourage you to consider getting started with treatment times outside of the after-school timeframe.

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Parent/Guardian's Information

Disclosure for Text Messaging*

I agree

I agree to receive communications by text message about my inquiry. You may opt-out by replying STOP or reply HELP for more information. Message frequency varies. Message and data rates may apply. You may review our privacy policy to learn how your data is used. Your personal information is important to us. It will not be shared or sold to any third parties for marketing purposes. You may unsubscribe from our messages at any time by replying STOP.

Please indicate the preferred clinic location where you are seeking services*

Leawood Clinic

Prairie Village Clinic

In order to start services for your child sooner, are you open to being scheduled at a different location?*

Yes

No

What services are you seeking?*

Primary Insurance Card Information*

Insurance companies require that we have both the Primary and Secondary insurance cards on file to insure proper Coordination of Benefits (COB). If you have Primary and Secondary coverage, please send copies of both insurance cards.

Front of your insurance card*

Back of your insurance card*

If other, please specify:

First Name of the Policy Holder?*

Last Name of the Policy Holder?*

What is the Gender of the Policy Holder?*

Male

Female

Policy Holder DOB*

Member ID Number*

Group #*

Re-enter Group #*

Plan Name*

Plan Phone Number*

Is this an Aetna plan through HCA, Meritain, Carpenters, or Trustmark?

HCA

Meritain

Carpenters

Trustmark

Secondary Insurance*

If other, please specify:

I'm a current or previous Playabilities family...*

Seeking Services for Same Child

Seeking Services for Sibling

Name of referral:*

If other:*

Name of Medical Practice:*

Name of Physician/Pediatrician:*

Name of Parent Educator:*

Name of School:*

Name of Playabilities Employee:*

Other:*