A Chance To Grow - Brain-Centered Therapy Services

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    • Clinical Services >
      • Client Forms
      • Vision Services >
        • Vision Clinic
        • OptomEYES Vision Therapy
      • Occupational Therapy
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      • Neuro Integrative Clinic >
        • Treatment Models
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      • Audiology Services >
        • Auditory Processing
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          • JIAS
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          • Acoustic Pioneer
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      • Teletherapy Services
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      • Neurofeedback >
        • Neurofeedback Rentals
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        • Brain Spa
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        • Advanced-Brain Wellness Program
        • AVE Store
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    • Home-Based / PCA's >
      • Get Started / Qualify
      • Waiver Services
      • Intake Form
      • Become a PCA
    • MLRC / S.M.A.R.T. >
      • S.M.A.R.T. Program >
        • How S.M.A.R.T. Works
        • S.M.A.R.T. at My School
        • S.M.A.R.T. Mentoring
        • S.M.A.R.T. Steps
        • Research & Resources
      • Workshops >
        • S.M.A.R.T. Elementary
        • S.M.A.R.T. Pre-K
        • Bridging The Gap
        • Auditory Processing Workshops
        • Hosting a Workshop
        • Registration Policy
      • S.M.A.R.T. Supplies >
        • Downloads
    • School Services >
      • Third-Party Billing
      • Vision & Hearing Screenings
    • Turnquist Childcare >
      • Curriculum & Assessment
      • Teen Parent Program
      • Enrollment Forms
    • Summer Programs >
      • Neuro Integrative Intensives
      • Advanced-Brain Summer Intensives
  • Parents
    • Helpful Resources
    • Testimonials
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    • Workshops
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    • Success Stories
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  • Donate
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  • Home
  • About
    • Mission
    • History
    • Board of Directors
    • Honorary Spaces
    • Annual Report
    • Contact
    • Bob's Legacy Fund
  • Programs & Services
    • Clinical Services >
      • Client Forms
      • Vision Services >
        • Vision Clinic
        • OptomEYES Vision Therapy
      • Occupational Therapy
      • Speech Therapy
      • Neuro Integrative Clinic >
        • Treatment Models
        • NI Clinic Pricing
      • Audiology Services >
        • Auditory Processing
        • Workshops
        • Auditory Interventions >
          • JIAS
          • CAPDOTS
          • Acoustic Pioneer
      • Insurance Payers
      • Teletherapy Services
    • Brain Training >
      • Neurofeedback >
        • Neurofeedback Rentals
        • Advanced-Brain Summer Intensives
        • Brain Spa
      • Audio-Visual Entrainment >
        • Advanced-Brain Wellness Program
        • AVE Store
      • Brain-Training Workshop Series
    • Home-Based / PCA's >
      • Get Started / Qualify
      • Waiver Services
      • Intake Form
      • Become a PCA
    • MLRC / S.M.A.R.T. >
      • S.M.A.R.T. Program >
        • How S.M.A.R.T. Works
        • S.M.A.R.T. at My School
        • S.M.A.R.T. Mentoring
        • S.M.A.R.T. Steps
        • Research & Resources
      • Workshops >
        • S.M.A.R.T. Elementary
        • S.M.A.R.T. Pre-K
        • Bridging The Gap
        • Auditory Processing Workshops
        • Hosting a Workshop
        • Registration Policy
      • S.M.A.R.T. Supplies >
        • Downloads
    • School Services >
      • Third-Party Billing
      • Vision & Hearing Screenings
    • Turnquist Childcare >
      • Curriculum & Assessment
      • Teen Parent Program
      • Enrollment Forms
    • Summer Programs >
      • Neuro Integrative Intensives
      • Advanced-Brain Summer Intensives
  • Parents
    • Helpful Resources
    • Testimonials
    • Share Your Story
  • Events
    • Workshops
    • Race for the Children
    • Partners & Sponsors
  • News & Media
    • Growing Times
    • S.M.A.R.T. Newsletter
    • Success Stories
    • Photo Release
  • Donate
    • Garden of Hope
  • Store
    • Shipping & Returns

Client ​FORMS


Ready to
get started?

Minor Client Intake Form
Ingreso de Clientes Menores
Adult Client Intake Form
Ingreso de Clientes Adultos
Forms for all services, except for the Vision Clinic, can be found in our new medical record system. Click the button to access the RainTree Patient Dashboard. If dashboard page doesn't load, please try refreshing the page.
RainTree Patient Dashboard
*Clients have multiple options to pay their bills. You may pay for individual services through the RainTree Portal, request monthly statements be sent to you via text or email, or be mailed a physical copy of your statement and pay with a check or card. For questions related to setup or billing, please call (612) 789-1236 or email actg@actg.org.

RainTree FAQ


Below you will find additional clinic forms that are not currently available in the RainTree Dashboard. Please consult our client support staff regarding which forms are required for you. All forms can be filled out online, but it you prefer, we can provide hard copies that can be filled out and submitted in-person or via fax. A Chance To Grow's fax line is (612) 746-5144. 
 
For questions regarding client forms, please contact us by calling (612) 789-1236 or email schedule@actg.org. 

Vision Clinic

Annual Health & Vision Health History

Consent Forms

​Formularios de la Clínica de la Vista
​
Aviso de Prácticas de Privacidad de HIPAA, Autorización Basada en Seguros y Consentimiento para Tratar

Historial Anual de Salud y Salud de la Vista​

Audiology Clinic

​Johansen Checklist

Auditory Addendum


Lista de Verificación de Johansen

​​
​Apéndice de Audiología

Neurotechnology

Neurofeedback Consent Form
​
Cognitive Function Questionnaire


Emotional Inventory

​
Checklist of Client Concerns

Tracking Your Progress


Attention Assessment (Child)

​
Attention Assessment (Teen/Adult)

​
Spectrum Assessment Form (Neurofeedback)

Audio-Visual Entrainment Consent Form

Additional Forms

Authorization for Access, Release and Use of Educational Information

Authorization for Access, Release and Use of Medical Information
​

Insurance and Identification Card Upload
​
If you have new insurance or received a new insurance card, please take a photo using the tools in this form to upload your updated insurance card and state ID. 

Spanish Forms

​Autorización para Acceso, Divulgación y Uso de Información Médica

Autorización para Acceso, Divulgación y Uso de Información Educativa

Client ​FORMS


Ready to get started?

Minor Client Intake Form
Ingreso de Clientes Menores
Adult Client Intake Form
Ingreso de Clientes Adultos
Forms for all services, except for the Vision Clinic, can be found in our new medical record system. Click the button to access the RainTree Patient Dashboard. If dashboard page doesn't load, please try refreshing the page.
RainTree Patient Dashboard
*Clients have multiple options to pay their bills. You may pay for individual services through the RainTree Portal, request monthly statements be sent to you via text or email, or be mailed a physical copy of your statement and pay with a check or card. For questions related to setup or billing, please call (612) 789-1236 or email actg@actg.org.

RainTree FAQ


Below you will find additional clinic forms that are not currently available in the RainTree Dashboard. Please consult our client support staff regarding which forms are required for you. All forms can be filled out online, but it you prefer, we can provide hard copies that can be filled out and submitted in-person or via fax. A Chance To Grow's fax line is (612) 746-5144. 
 
For questions regarding forms, contact us at (612) 789-1236 or email schedule@actg.org. 

Vision Clinic

Annual Health & Vision Health History

Consent Forms

Formularios de la Clínica de la Vista
​
Aviso de Prácticas de Privacidad de HIPAA, Autorización Basada en Seguros y Consentimiento para Tratar

Historial Anual de Salud y Salud de la Vista​

Audiology Clinic

​Johansen Checklist

​Auditory Addendum

Lista de Verificación de Johansen
​
​
​Apéndice de Audiología



Neurotechnology

Neurofeedback Consent Form

Audio-Visual Entrainment Consent Form
​

Cognitive Function Questionnaire


Emotional Inventory

​
Checklist of Client Concerns

Tracking Your Progress


Attention Assessment (Child)

​
Attention Assessment (Teen/Adult)

​
Spectrum Assessment Form (Neurofeedback)

Additional Forms

Authorization for Access, Release and Use of Educational Information

Authorization for Access, Release and Use of Medical Information
​

Insurance and Identification Card Upload
​
If you have new insurance or received a new insurance card, please take a photo using the tools in this form to upload your updated insurance card and state ID. 

Spanish Forms

Autorización para Acceso, Divulgación y Uso de Información Médica

​Autorización para Acceso, Divulgación y Uso de Información Educativa
Our Mission is to promote the maximum development of the whole child and adult through innovative, individualized and comprehensive brain-centered programs and services.
Location & Contact Information
1800 NE 2nd Street, Minneapolis, MN 55418
(612) 789-1236 / actg@actg.org

Main Fax: (612) 706-5555
Fax for Home-Based Services: (612) 706-5509
Fax for Clinical Services: (612) 746-5144

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A Chance To Grow is a 501(c)(3) non-profit organization. Gifts are tax-deductible. ACTG does not discriminate on the basis of race, sex, religion, age, disability, sexual orientation, or marital status.
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