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Skills Training Program

Helping every child conquer in all areas of life.

Date picker*

Guardian First name*

Guardian Last name*

Phone Number*

Email Address*

Relationship to Child*

How many children under the age of 18 do you have that are in need of services?*

Child 1-First Name/Last Name *

Child 1 Date of Birth*

Month

Day

Year

Child 1 PID Number (DFPS Children Only)

Child 2-First Name/Last Name

Child 2 Date of Birth

Month

Day

Year

Child 2-PID Number (DFPS Children Only)

Child 3-First Name/Last Name

Child 3 Date of Birth

Child 3-PID Number (DFPS Children Only)

Additional Children-First Name/Last Name and Date of Birth

Additional Children-PID Number (DFPS Children Only)

Street Address*

City and State*

Zip Code

Does your child have a mental health diagnosis?*

Yes

No

I am not sure, but would like an assessment

What is your child's diagnosis? If unknown enter N/A

Is your child enrolled in Texas Medicaid?*

Yes

No

Who is your child's Medicaid Managed Care Organization?*

Aetna

Amerigroup (WellPoint)

Blue Cross Blue Shield

Community Health Choice

Molina

Superior

Texas Children's Health Plan

Other

What services are you interested in?*

CANS/ANSA Assessment

Case Management

Behavioral/Life Skills Training

Medication Management

Mental Health Therapy

Other

Upload Copy of Guardian ID

Upload Copy of Child 1 Insurance Card*

Upload Copy of Child 2 Insurance Card

Upload Copy of Child 3 Insurance Card

Upload Copy of Child 4 Insurance Card

Referral Source (Who referred you to our program)*

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