Name
*
First Name
Last Name
Contact Number:
*
E-mail
*
example@example.com
Child's Name and Age:
*
Child's Name
Age
Insurance Provider
*
What services are you interested in?
*
Developmental Therapy
Behavior Therapy
Applied Behavioral Analysis
Feeding Therapy
Speech Therapy
Occupational Therapy
Family Counseling
Other
Does your child nap during the day? If yes, when?
*
What times/days of the week is your child available to receive therapy services?
*
How has your child's health been? (Please include discussion of illnesses, hospitalizations, surgeries, serious injuries, ear infections, tubes in ears, allergies, seizures, etc.)
Does your child take any prescribed medications or use any adaptive equipment? If yes, please provide what for.
Was your child full term?
Please Select
Yes
No
Birth weight?
Premature?
Please Select
Yes
No
If your child was premature, please provide the number of weeks in which they were born at:
What kind of delivery did you require for your child?
Please Select
Vaginal
C-Section
Any birth injuries? Please describe if yes.
Which location are you interested in? (In home, daycare/school, Pyramid Preschool- 3048 N Milwaukee, or Learning Through Play- 633 W Addison)?
*
Additional Comments:
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