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Contact Form
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10
Questions
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1
Parent/Guardian Name
First Name
Last Name
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2
Child's Name
First Name
Last Name
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3
Who Referred You?
First Name
Last Name
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4
Email
example@example.com
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5
Phone Number
Please enter a valid phone number.
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6
Date
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Date
Month
Day
Year
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7
What is the best time to contact you by phone or would you prefer an email or text? Let us know!
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8
What is the age and grade level of your child (if applicable)?
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9
What Are Your Main Concerns?
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10
Please Check Some Additional Concerns:
Seems to know something one day but not the next
High pain tolerance
Motion sickness/dizziness
Difficulty reading
Difficulty spelling
Difficulty with math
Socially immature
Few Friends
Bothered by tags and or seams
Overly sensitive to odors
Overly sensitive to sound
Overly sensitive to light
Bedwetting
Picky Eater
Poor pencil grasp
Experiences fear or anxiety
Clumsy
Tics
Picky Eater
Toe Walking
Focus
Issues with Tonal Processing
Fine motor
Likes to get everyone stirred up, then sits back and enjoys the chaos
No empathy for others
Eye issues - lazy eye, tracking, central detail vision, etc.
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