Scheduling Request

Scheduling Request
Please complete the form and a member of our staff will contact you to assist with your request.

If you already know what service you need, you may skip this form and complete a Minor Client Intake or an Adult Client Intake form. Thank you!
Client Name:

First Name Last Name
Contact Name:

First Name Last Name
Phone Number:
Please enter a valid phone number.
Email:
example@example.com
Contact Relation to Client:
Age of Client
Preferred Method of Contact:

Phone Email Text
May we leave a detailed message?

Yes No
Best time to contact you?

Morning Afternoon Evening
Which Clinical Services are you interested in?

Occupational Therapy Speech-Language Therapy Vision Clinic OptomEYES Vision Therapy Audiology Clinic Neuro Integrative Clinic Neurofeedback & Audio-Visual Entrainment Teletherapy (OT and Speech)
Please share with us a brief description of your situation:
Should be Empty: