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13
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1
Child Full Name
*
This field is required.
First Name
Last Name
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2
Your Full Name
*
This field is required.
First Name
Last Name
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3
School Name
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4
Your Phone Number
*
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Contact Phone Number
Example: +201203473311
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5
Phone Number
*
This field is required.
Please enter a valid phone number.
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6
Your Email
*
This field is required.
example@example.com
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7
Relationship to Child
*
This field is required.
Parent
Grandparent
Practitioner/Educator/Therapist
Other Family Member
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8
Contact Number
*
This field is required.
Area Code
Phone Number
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9
Child Age
*
This field is required.
Age in Years Example: 8
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10
Child Date of Birth (DOB)
*
This field is required.
/
Date
Day
Month
Year
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11
Location
*
This field is required.
Current Residence or School/Nursery Location
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12
Child's School/Nursery
*
This field is required.
If none type "N/A"
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13
Expected Start Date
*
This field is required.
School/Nursery expected start date
/
Date
Day
Month
Year
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14
I would be interested in the following services
*
This field is required.
Choose as many as you like
School Integration Teacher (SIT)/Shadow Teacher Service
In-Home Sessions
In-School Sessions
Virtual Sessions
Playground Sessions at our LifeStyle PlayGrounds
Group & Social Sessions
Holidays Activities and Camps
Activity PAL
One-on-One Relational Behavioural Modification; Social and Emotional Learning and/or Daily Life Skills (Supermarket; Mall; Club Sessions)
Parent Support Groups
One-on-One Parent Sessions
Family Psychotherapy
Speech Group Sessions
Speech one-on-one Sessions
Occupational Therapy Sessions
Sensory Integration Therapy Sessions
Literacy and Numeracy Sessions
Formal Assessments
Informal Assessments
Plans and Guides for Teachers for at-School interactions
Plans and Guides and Support for at-home interactions
Other
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15
Please give us a small description about your current needs
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16
Client ID
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