About us
What's happening
Questions
Welcome
Enroll my Child
Make a referral
Medical Professionals
Parent Inquiry form
Parent Corner
News
en Espanol
Careers
About us
What's happening
Questions
Welcome
Enroll my Child
Make a referral
Medical Professionals
Parent Inquiry form
Parent Corner
News
en Espanol
Careers
Parents & Guardians.... fill out this form to get started
Child's Name
*
First Name
Last Name
Presenting Problem
List all that apply
Gross Motor issues
Balance Issues
Fine Motor/ Coordination issues
Speech issues
Chewing/ Swallowing problems
Vision issues
Hearing issues
Asthma
Complicated Medical history
Child's Date of Birth
Medicaid Number
If none, please state that.
Name of parent or guardian
First Name
Last Name
Parent/ guardian phone number (if applicable)
Your phone number
Your email address
*
Birth questions
What gestational week was the child's birth? (how far along was the mother when the child was born?)
Did the child pass a hearing test at birth?
Yes
No
Did not take one
Medical History
Does your child have a current diagnosis(es)?
Yes
No
If so, please list all diagnosis(es)
Examples might be Muscular Dystrophy, Cerebral Palsy, Asthma, ADHD, Downs Syndrome, Autism, etc.
Are they currently receiving treatment or intervention?
Yes
No
Not currently, but he/she has received in the past
Is the child currently on any medications?
How did you initially hear about us?
*
Please check all that apply
Medical Professional
referred from a friend
Social Media
TV Commercial (KARK 7- "Steve Harvey Show")
TV Commercial (Fox 16)
Were your referred by a doctor, nurse, therapist, or caseworker?
*
Yes
No
If so, please tell us who.
*
Please list the name of the office or person who referred you.
Additional Notes
Thank you!
