Schedule an Appointment

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To request an appointment with one of our providers or a space in one of our groups, fill in the following form. Items displayed like this are required.

All the clinicians at KidsLink are out-of-network medical service providers. This means that full payment will be due at the time of your appointment. You will be provided with a reimbursement form that you may submit to your insurance provider, per the guidelines of your individual policy. Be sure to check with your insurance company for details regarding percent reimbursement for out-of-network services.

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Please choose a provider or service.

Has your child ever been seen at KidsLink?

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Reason for Visit:
Time Preference:
Day Preference:

Child's Name:

Child's Date of Birth:

Parent's Name:

Phone Number:

Address:

Street:
City:
State:
Zip:

E-mail Address:

Additional Information: