School Admissions Inquiry

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

All form fields are required. Please do not include any identifying or medical details beyond what is requested. Your privacy is our priority.

Contact Name (Not Student Name) is not valid.
Email Address is not valid.
Phone Number is not valid.
Relationship to Student/Title & Agency is not valid.
Child's State of Residence is not valid.
Child's Age is not valid.
What is the child's funding source for potential placement at Heartspring? (check all that apply) is not valid.
Other funding source is not valid.
Does the child have a primary diagnosis of a neurodevelopmental disorder (NDD) like autism or an intellectual disability? is not valid.
Please enter their primary diagnosis or diagnoses is not valid.
Does the child have complex medical needs (beyond an NDD) that require specialists’ care like neurological or gastrointestinal conditions or concerns? is not valid.
Please describe is not valid.
  1. Expressed suicidal or homicidal ideation
  2. Planful or premeditative in their harm of others
  3. Use objects as weapons to attack
  4. Engage in sexually deviant, aggressive, or inappropriate behavior
  5. Substance use/abuse
  6. History of fire-setting or cruelty toward animals
  7. Experienced auditory or visual hallucinations
Please describe is not valid.

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.