Start Services

1

Child Information

First Name *

Middle Name

Last Name *

Date of Birth *

Home Address

2

Caregiver Information

First Name *

Middle Name

Last Name *

Email *

Phone Number *

Do you have signing authority for this child? *

YesNo

3

Medical History

Known Diagnoses *

Select all that apply.

4

Services Requested

Occupational Therapy (OT) *

Assessment and Treatment SessionsAssessment OnlyTreatment Sessions OnlyNone

Speech-Language Therapy (SLP) *

Assessment and Treatment SessionsAssessment OnlyTreatment Sessions OnlyNone

Behavior Consultation & Intervention *

Assessment and Treatment SessionsAssessment OnlyTreatment Sessions OnlyNone

5

Availability

Select the time slots when your child is available for sessions. Check all that apply for each day.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

6

Funding

How will services be funded? *

Select all that apply.

7

Additional Information

Anything else you would like us to know?

Child Information

Caregiver Information

Medical History

Services Requested

Availability

Funding

Additional Information

What happens next?