Elite Healthcare Group | Enrollment Form

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Newly Renovated Facilities | New Indoor Interactive Gym

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Simply complete the enrollment form below to apply for services from Elite Healthcare Group. Upon submission of the form, a member of our team will contact you in a timely manner to set up an in-person consultation.

Client Information

Client's First Name * Client's Last Name * Date of Birth * Gender * Street Address * City * State * Zip / Postal Code * How did you find out about us? * Diagnosis(es) * ASD Diagnosis Date * Diagnosing Physician * Primary Physician * Physician's Phone # *

Behavioral Information

Does the child exhibit any of the following behaviors? (Check All that Apply)

Self-Injurious Behaviors Physical Aggression Verbal Aggression Property Destruction Stereotypical/Repetitive Behaviors Unusual Sleep Patterns Elopement Tantrums Inappropriate Touching Verbal Threats Others (List Here)

Parent/Guardian Information

First Name of Parent/Guardian * Last Name of Parent/Guardian * Relationship to Client * Street Address of Parent/Guardian * City of Parent/Guardian * State of Parent/Guardian * Zip Code of Parent/Guardian * Email Address of Parent/Guardian * Primary Phone # of Parent/Guardian

1201 N Martin Luther King Jr. Dr., Winston-Salem, NC 27101
Monday-Friday: 8 AM - 6 PM
elevationpediatrictherapy.org | [email protected]
Phone: 336-579-3560 | Fax: 336-579-3561