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Beneficiary Registration

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- Step 1 of 3

Getting Started

BENEFICIARY

Name *

First

Middle

Last

Date of Birth *

Sex

RESPONDENT

Relationship to Beneficiary *

Relationship to Beneficiary *

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Contact Information

BENEFICIARY

Phone *

Do you use Signal for messaging?

Yes
No

Staff use Signal for secure messaging. They may also use SMS/MMS/RCS, but privacy regulations restrict their usage of WhatsApp.

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

LEGAL REPRESENTATIVE (RESPONDENT)

Name *

First

Last

Phone *

Do you use Signal for messaging?

Yes
No

Staff use Signal for secure messaging. They may also use SMS/MMS/RCS, but privacy regulations restrict their usage of WhatsApp.

Email *

Address (if different)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Add Legal Representative

Add Legal Representative

SECOND LEGAL REPRESENTATIVE

Relationship to Beneficiary *

Relationship to Beneficiary *

Name *

First

Last

Phone

Email

Address (if different)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

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Support Request

I am interested in:

Applied Behavior Analysis
Occupational Therapy
Speech-Language Pathology

Beneficiary Diagnosis

Anxiety
Aphasia
Autism Spectrum Disorder
Attention Deficit Hyperactivity Disorder
Behavior disorder
Cerebral palsy
Childhood apraxia of speech
Dementia
Depression
Developmental Disorder
Dyslexia
Dysphagia
Hand injury or condition
Intellectual disability
Language disorder
Post-traumatic stress disorder
Sensory processing disorder
Speech sound disorder
Stuttering or other fluency disorder
Traumatic brain injury
Cognitive-communication disorder
Voice disorder
Other

Other Diagnoses

Autism Level

Autism levels only apply to the DSM-V, which has been adopted some countries (e.g., the US) and not others (e.g., Germany)

Funding

Aetna/AFSPA
BCBS/FEP
Cigna
German Health Insurance
Jugendamt/Sozialamt
Private Pay
TRICARE
Other

Other Funding

GDPR Agreement *

I consent to having this website store my submitted information so they can respond to my inquiry.

Save and Resume Later

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Email *

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