CARE Social Club Application

We use this information to decide how to best serve your child. Upon receipt and review of the form, we will follow up with you to discuss your family’s needs in more detail and review the next steps. Your privacy is our priority. All form submissions are secure on Heartspring’s HIPAA-compliant servers.

Parent's/Guardian's Phone Number*

Please Explain:*

Identify three top priorities for skills that you would like to see addressed in CARE Clubs. Please choose targets that you feel will have the most impact for your child and your family.*

Is he or she able to self-administer?*

My child’s interests include:*

My child does NOT enjoy:*

Please Explain:*

Any additional questions or comments for our team?*

CARE services will resume January 2026!

CARE Clubs Application

Heartspring

CARF Accredited