Go to St. Mary's Kids Home
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Careers
Events
News
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Go to St. Mary's Kids Home
About
Our Mission
Our History
Our Leadership
Our Staff
Programs & Services
Inpatient Services & Long-Term Care
Rehabilitation
Aquatic Therapy
Neuro-Rehabilitation
Respiratory Therapy
Nursing
Healing Arts & Therapeutic Recreation
Complementary Care
Pediatric Feeding Disorders
Palliative Care
Respite Care
Spiritual Care
Spinal Cord Injury Rehabilitation
Day Services
Medical Day Healthcare Program
Center for Pediatric Feeding Disorders
Early Childhood Services
Helping Hands Program
Extraordinary Pediatrics
Home Care
Care in the Home
Early Education
Special Needs Preschool
CPSE Evaluations
SEIT Services
Community Programs
Care Coordination Services
Community Care Professionals
Family Training
For Families
Get To Know Us
Your Stay at St. Mary’s
Family Services
What to Expect
Visitor Guidelines
Resident Rights
Family Newsletter
Family as Partners in Care
Grievance Process
Ways To Give
Donate
Annual Fund
Corporate Giving
Planned Giving
Tribute Gifts
Special Initiatives & Campaigns
In-Kind Giving
Giving Societies
Friends of St. Mary’s
Volunteer
Giving Tuesday
Shop to Support
Greeting Cards
Why Give
Donor Stories
Your Impact
Patient Stories
Donate
Home
Programs & Services
Appointment / Inquiry Request Form
Appointment / Inquiry Request Form
Date
Has your child previously received care at any of St. Mary's Programs?
*
Yes
No
Patient Full Name
*
First
Last
Date of Birth (MM/DD/YY)
*
Gener
*
Male
Female
Address
*
Parent Information
Parent Full Name
*
First
Last
Home Phone
*
Cell Phone
Email
*
Preferred Method of Communication
*
Home Phone
Cell Phone
Email
Insurance Information
Does the patient have insurance?
*
Yes
No
Primary Insurance:
Secondary Insurance (if applicable):
Medical Information
Which of the following primary diagnoses applies to your child?
*
Spinal Cord Injury
Acute Flaccid Myelitis
Guillain-Barré Syndrome
How long has your child had this diagnosis?
*
Does child have any other medical condition/s? (Please list all)
*
How did you hear about us?
*
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About
Our Mission
Our History
Our Leadership
Our Staff
Programs & Services
Inpatient Services & Long-Term Care
Rehabilitation
Aquatic Therapy
Neuro-Rehabilitation
Respiratory Therapy
Nursing
Healing Arts & Therapeutic Recreation
Complementary Care
Pediatric Feeding Disorders
Palliative Care
Respite Care
Spiritual Care
Spinal Cord Injury Rehabilitation
Day Services
Medical Day Healthcare Program
Center for Pediatric Feeding Disorders
Early Childhood Services
Helping Hands Program
Extraordinary Pediatrics
Home Care
Care in the Home
Early Education
Special Needs Preschool
CPSE Evaluations
SEIT Services
Community Programs
Care Coordination Services
Community Care Professionals
Family Training
Free NYS Car Seat Inspections
For Families
Get To Know Us
Your Stay at St. Mary’s
Family Services
What to Expect
Visitor Guidelines
Resident Rights
Family Newsletter
Family as Partners in Care
Grievance Process
Ways To Give
Donate
Annual Fund
Corporate Giving
Planned Giving
Tribute Gifts
Special Initiatives & Campaigns
In-Kind Giving
Giving Societies
Friends of St. Mary’s
Volunteer
Giving Tuesday
Shop to Support
Greeting Cards
Why Give
Donor Stories
Your Impact
Patient Stories
Donate
Visitor Info
Contact & Locations
Careers
Events
News
Blog
About
Our Mission
Our History
Our Leadership
Our Staff
Programs & Services
Inpatient Services & Long-Term Care
Rehabilitation
Aquatic Therapy
Neuro-Rehabilitation
Respiratory Therapy
Nursing
Healing Arts & Therapeutic Recreation
Complementary Care
Pediatric Feeding Disorders
Palliative Care
Respite Care
Spiritual Care
Spinal Cord Injury Rehabilitation
Day Services
Medical Day Healthcare Program
Center for Pediatric Feeding Disorders
Early Childhood Services
Helping Hands Program
Extraordinary Pediatrics
Home Care
Care in the Home
Early Education
Special Needs Preschool
CPSE Evaluations
SEIT Services
Community Programs
Care Coordination Services
Community Care Professionals
Family Training
For Families
Get To Know Us
Your Stay at St. Mary’s
Family Services
What to Expect
Visitor Guidelines
Resident Rights
Family Newsletter
Family as Partners in Care
Grievance Process
Ways To Give
Donate
Annual Fund
Corporate Giving
Planned Giving
Tribute Gifts
Special Initiatives & Campaigns
In-Kind Giving
Giving Societies
Friends of St. Mary’s
Volunteer
Giving Tuesday
Shop to Support
Greeting Cards
Why Give
Donor Stories
Your Impact
Patient Stories
Donate
