New Application

Welcome to the Patient Application System. This tool is used by Children's Behavior Therapy to manage Patient applications. We are glad you've decided to apply at Children's Behavior Therapy.

Enrollment

Application for Admission

All fields marked with (*) are required

Patient’s First Name (*)

Patient’s Middle Name

Patient’s Last Name (*)

Birthdate (MM-DD-YYYY)

Diagnosis

If other diagnosis

Parent / Guardian Information

First Name (*)

Last Name (*)

Cell_Phone (*)

IMPORTANT: Please use a cell phone number that you use frequently, as the school will contact you at this number.

E-Mail (*)

IMPORTANT: Please use an Email address that you monitor often as the school will be contacting you at this email address.

City

Services (*)

Funding Source

What other?

Application Confirmation

Patients must also reside in Florida to be able to apply to Children's Behavior Therapy.

Please wait, we are processing your request...

I acknowledge that the child listed in this application resides in Miami-Dade or Broward County and that as the parent/guardian of the child, I am inquiring about being admitted to the Children's Behavior Therapy ABA program. I agree that Children's Behavior Therapy may contact me at the phone number or email address I provided in the application.