Contact Us

Reason for contacting us*
Tour Our CenterSchedule An Assessment

Child's Name*

Parent/Guardian Name*

Child Date of Birth*

Address*

City*

State*
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Zip*

County of Residence*

Home Phone Number*

Work/Daytime Phone Number*

Your Email*

Home Consultant?
Yes No 

If yes, Name of Consultant

Home School District

Your Child's current funding resources (check all that apply): *
 Medicaid Card Caresource Card Level I Waiver IO Waiver Autism Scholarship Program Transition Waiver Home Health Waiver

Has your child been diagnosed with a genetic disorder, medical condition, autism, mental retardation, or any mental health or behavior problem? *
List answer and diagnosis here

How did you hear about our services? Check all that apply: *
 Friend Step By Step News Publication SBSA Web site Physician/Pediatrician Step By Step Academy Mailing County Board of MRDD School District Internet (web search, links, etc.) Other

Email Subject Line*

Your Message
Type any additional comments or questions here.