Contact Us info@beautifulmindssd.com(605) 608-0833 Child's Name * First Name Last Name Child's Date of Birth * MM DD YYYY Parent/Guardian Name * First Name Last Name Email * Phone Number * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Does you Child have an Autism diagnosis? * Yes No In Progress If yes, who provided the diagnosis? Primary Insurance Member ID Preferred session Times Morning Mid Day Afternoon After School ANY Preferred Therapy Location Clinic (Rapid City) Home No Preference Days Available for Therapy-Select All Monday Tuesday Wednesday Thursday Friday When would you like to start services? What are your top concerns or goals for your child? (e.g., communication, behavior, social skills, school readiness, daily living) Has your child received ABA therapy before? yes no How did you hear about Beautiful Minds? Thank you!
