Intake Form

Once you fill out the intake form and let us know a little more about your child, we will be in touch within 2 business days to schedule your Initial Evaluation.

 
Your Name *
Your Name
In which state will you need services provided?
Do you have a laptop or tablet with a camera and a microphone? *
Do you have reliable internet? *
What time of day typically works best for you?
Name of person receiving services.
Name of person receiving services.
We do require that there is an adult in the room to help facilitate the service, do you have someone identified? *
Has he/she received therapy services before? *
If the answer to the above was yes, were the services beneficial?
Does your child have any siblings? *
Has your child received any medical diagnosis? *
 

Want to chat through your options or next steps?