Registration Form

To begin our intake process, please complete the form below.

New Client Registration

Once your form is submitted, we will begin to verify your insurance benefits. We are not responsible for any incorrect information given to Spectacular Kids by the insurance company about your benefits. Verification of benefits does not guarantee coverage of services nor is Spectacular Kids responsible for how claims are processed by your insurance company.

Client Registration

1. Client Information

2. Family Information

Please provide complete contact info for at least one parent.

Primary's Name*

**Our Intake Coordinator will contact you to solidify your date and time.**

3. Services

4. Insurance Information

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