Application for Services

Please fill out the form below if you wish to be considered for services. Take note that the form is long, so please have all information available upon beginning the form. 

 
 
Child's Name *
Child's Name
Child's Birthdate *
Child's Birthdate
Keep in mind, we are open from 8:30-5pm on Monday through Friday.
Program Request *
Select all that apply
MEDICAL HISTORY
Please include date as well as diagnosing physician
Please include dates
Please include dates and results.
Please include dates and results.
If yes, please describe.
If yes, please list procedures, hospital used, and dates.
If yes, please list date, hospital, and reason.
If yes, please describe.
Has your child ever had problems with the following: *
Select all that apply.
E.g. premature birth, gestational diabetes, serious illness during pregnancy, etc. If so, please describe.
Please include the 1) type of medication, 2) purpose of the medication, 3) who it was prescribed by, 4) how often the medication is taken, and 5) the dosage.
If so, please list.
If so, when? For what reason? How long did they see this professional for? Was it helpful?
E.g Neurology, MRI, EEG, genetics, gastroenterology, etc.
CURRENT CONCERNS
Please check all current concerns you have for your child. *
E.g. prior therapies or services (please include dates, frequency and type of service). Were these services effective?
AREAS OF CONCERN
Check all areas of behavioral concern: *
DIETARY ISSUES
If so, please describe.
Check all applicable dietary issues for your child: *
Sleeping Issues
Please check all applicable sleeping issues for your child: *
E.g. Homeopathic, medication, behavioral.
TOILETING ISSUES
Behavioral Concerns