Cognitive Connections Initial Contact Form
Child's Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Father's Name
*
First Name
Last Name
Father's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Father's Email
*
example@example.com
Father's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Mother's Name
*
First Name
Last Name
Mother's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother's Email
*
example@example.com
Mother's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Child's School
*
Which type of school is it?
*
Public
Private
Homeschool
Other
Does your child have any of the following?
IEP
IAP
504
If your child is receiving any accommodations, please list them.
Has your child been formally diagnosed with any impairment?
*
Yes
No
If yes, please explain.
If yes, is a professional or physician currently overseeing treatment for this impairment?
Yes
No
Has your child had any recent surgeries?
*
Yes
No
If yes, please explain.
Any medications?
*
Yes
No
If yes, please give reason for medication.
Any ongoing therapy?
*
Physical therapy
Occupational therapy
Speech therapy
None
If receiving therapy, please state frequency and duration of visits.
Any allergies?
*
Yes
No
Any limitations or concerns in the home environment?
*
Yes
No
If yes, please explain.
Any limitations or concerns in the school environment?
*
Yes
No
If yes, please explain.
Any limitations or concerns in social environments?
*
Yes
No
If yes, please explain.
What are your primary struggles or concerns?
*
Any health concerns?
Any additional information?
How did you hear from us?
*
Newspaper
Facebook
Instagram
Website
Radio Station
Friend
Other
Referral
If Referral, who?
Which radio station, newspaper, or friend?
Submit
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