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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

Your Contact Information

Name*

First Last

Relationship to Student/Title & Agency*

Phone Number*

Phone Type*

Office

Mobile

Home

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Student Information

Name*

First Last

Age*

Birthday*

MM slash DD slash YYYY

Gender*

Child's State of Residence*

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

School District Funding

Medicaid

Child Welfare/Government Agency

Other

Please specify*

Is this funding source confirmed?*

Yes

No

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*

Full Scale IQ (if available)

Does the child have any medical conditions, allergies, or other health concerns that need ongoing care?*

Yes

No

Please describe*

Do any of the following statements apply to the child?

History of fire-setting or cruelty toward animals*

Yes

No

Please describe:*

Substance use/abuse*

Yes

No

Please describe:*

Planful Elopement/Ran Away*

Yes

No

Please describe:*

Expressed suicidal or homicidal ideation*

Yes

No

Please describe:*

Experienced auditory or visual hallucinations*

Yes

No

Please describe:*

Planful or premeditative in their harm of others*

Yes

No

Please describe:*

Use objects as weapons to attack*

Yes

No

Please describe:*

Engage in sexually deviant, aggressive, or inappropriate behavior*

Yes

No

Please describe:*

Additional Questions

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

How did you hear about Heartspring?

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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