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Contact Form
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10
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1
Parent/Guardian Name
First Name
Last Name
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2
Who Referred You?
First Name
Last Name
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3
Child's Name
First Name
Last Name
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4
Sex
Male
Female
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5
Email
example@example.com
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6
Phone Number
Please enter a valid phone number.
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7
Initial Contact
What is the best time to contact you? Would you prefer to be contacted initially by phone, email or text? Please 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 for your child?
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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 Anxiety
Experiences Various Fears - Fear of the Dark, Boogie Man Under the Bed, etc.
Clumsy
Tics
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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