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01 Aug

First Day Of School

At Knox Academy, we are dedicated to providing a nurturing and inclusive environment where students…

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Email Us

[email protected]

Call Us

601-800-4000
601-577-2363

ESA Approved Provider

At Knox Academy, we believe every child deserves an education tailored to their unique strengths and challenges.

Registration Inquiry

Student Information

First

Last

Sudent Date of Birth

Current School

Current Grade

Untitled

Male Female

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Parent Contact Information

Mother's Name

First

Last

Mother's Phone

Place of Employment

Business Phone Numbe

Father's Name

First

Last

Father's Phone

Father's Email

Place of Employment

Business Phone Number

Child History

Medical History

Languag

School District

Sex Assigned At Birth

Male Female

Guardian's Information

Relationship To Child

Father Mother Other

My address is the same as my child's address

Yes No

Diagnostic Information

Information about who evaluated / diagnosed your child.

Has your child been formally diagnosed with Autism by a doctor (MD, PHD, PSYD, etc)?

Yes No

Doctor's Phone Number

Pediatrician Information

Pediatrician's Phone Number

Available Services at ALP

Note: Service offerings may vary by location and clinician

Which ALP services interest you?

Early Intervention Center-based Services Home-based Services Partnered Diagnostician Services Speech, Occupational, or Physical Therapy (Select CA Locations Only)

Please check all that apply

Notice

If your child is under 5 years old:

Research supports an intensive approach to services for young children (under the age of 5) (Healy & Lydon, 2013). Our initial recommendations for Early Intensive Behavioral Intervention are typically between 20-35 hours per week. (In some states and locations we do half day and full day center based programs) To expedite scheduling, please indicate TWO time frames below that you will be available Monday – Friday. Your child's precise recommendation will be determined through an individualized clinical assessment.

Weekday Availability (M - F) for 5 yrs. and under

Please note: the exact start and end times for ABA therapy sessions will be determined at your child's first assessment with the clinic staff.

Please check all that apply

Early Start: 8 AM - 3 PM

8:00 AM to 12:00 PM

Midday: 12 PM - 6 PM

8:00 AM to 12:00 PM

Split: 8 - 11 AM in clinic, AND 3:30 - 6:30 PM in home

3:00 PM to 8:00 PM

Weekday Availability (M - F) for school-aged children

Please check all that apply

Afterschool Program: Flexible start time, about 15-20 hours a week determined by your child's clinical assessment.

8:00 AM to 12:00 PM

My child is homeschooled

3:00 PM to 8:00 PM

Weekend Availability

Do you also have availability on the weekend?

Please note weekend times are exclusively for make up sessions. Please check all that apply

How did you hear about us?

I was referred by

A friend A physician I was not referred

Policy Holder's Information

Policy Holder's Name

Policy Holder's Date of Birth

Relationship to child?

Father Mother Other

Does your child receive state-funded insurance?

Yes No

Primary Insurance Company

Insurance Phone Number (Primary)

Would you like to add a secondary insurer?

Yes No

Secondary Insurance Company

Policy ID (Secondary)

Insurance Phone Number (Secondary)

Upload a copy of the front and back of your CHILD'S Medical ID Card

First Day Of School

Explore Knox

Admissions

News & Events

Clinical Services

Registration Inquiry

Student Information

Parent Contact Information

Father's Name

Child History

Get Outstanding Autism Support...

If your child is under 5 years old:

Please note: the exact start and end times for ABA therapy sessions will be determined at your child's first assessment with the clinic staff.

Weekday Availability (M - F) for school-aged children

Do you also have availability on the weekend?