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Heartspring Therapeutic School Admissions Inquiry

Thank you for your interest in the Heartspring Therapeutic Residential & Day School! Please fill out the form below regarding a student you’d like to enroll in our program.

"*" indicates required fields

Contact

Name*

First Last

Relationship to student/Title & Agency*

Contact Information

Phone Number*

Email*

Student Information

Name*

First Last

Child's Age*

Child's State of Residence*

What is the child's funding source for potential placement at Heartspring? (check all that apply)*

Medicaid

School District Funding

Private Pay

Child Welfare/Government Agency

Other

Please specify*

Does the child have a primary diagnosis of a neurodevelopmental disorder (NDD) like autism or an intellectual disability?*

Yes

No

Please enter their primary diagnosis or diagnoses*

Does the child have complex medical needs (beyond an NDD) that require specialists’ care like neurological or gastrointestinal conditions or concerns?*

Yes

No

Please describe*

Do any of the following statements apply to the child?*

Expressed suicidal or homicidal ideation
Planful or premeditative in their harm of others
Use objects as weapons to attack
Engage in sexually deviant, aggressive, or inappropriate behavior
Substance use/abuse
History of fire-setting or cruelty toward animals

Yes

No

Please describe*

What questions do you have about Heartspring's Therapeutic School?

HIPAA Compliance

HIPAA Privacy Statement*

By submitting this form, you acknowledge and agree that any information provided will be handled in accordance with HIPAA regulations. Heartspring takes every precaution to ensure your sensitive information is protected. For more details on our privacy practices, view our Privacy Policy.

I have read and understand the HIPAA compliance notice and consent to the submission of this information.

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Heartspring
Heartspring is a place of possibility for kids the world underestimates. We assess, diagnose, treat, educate, and inspire children with neurodevelopmental needs.

Phone

Main Office: 316-634-8700

Toll-Free: 1-800-835-1043

Outpatient Scheduling: 316-634-8701

Outpatient Front Desk: 316-634-8710

Address

8700 E. 29th St. N.
Wichita, KS 67226

Email

General: info@heartspring.org

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