Parents & Guardians.... fill out this form to get started 

 

Child's Name *
Child's Name
Presenting Problem
List all that apply
If none, please state that.
Name of parent or guardian
Name of parent or guardian
Birth questions
Medical History
Does your child have a current diagnosis(es)?
Examples might be Muscular Dystrophy, Cerebral Palsy, Asthma, ADHD, Downs Syndrome, Autism, etc.
Are they currently receiving treatment or intervention?
How did you initially hear about us? *
Please check all that apply
Were your referred by a doctor, nurse, therapist, or caseworker? *
Please list the name of the office or person who referred you.