Dynamic Days Intensive Therapy Program Inquiry Form
Thank you for inquiring about our Dynamic Days Intensive Therapy Program. Once you have submitted the following information, our intake specialist will contact you to follow up on any additional information we might need to determine if Dynamic Days is the right fit for your child as well as to answer any questions you might have including giving you an estimate of financial responsibility.
How did you hear about us?
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DTS Team Member
Website
Google
Red Stick Mom Blog
BR Parents Magazine or Website
Facebook/Instagram
Pediatrician/Provider
Friend or Family
Other
Todays date
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Month
-
Day
Year
Date
Primary Caregiver's Information
Full Name (Primary Caregiver)
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Primary Caregiver's First Name
Last Name
Relationship to Child
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Phone Number
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Please enter a valid phone number.
Email
*
example@example.com
Child's Information
Child's Name
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Camper's First Name
Camper's Last Name
Date of Birth
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Month
-
Day
Year
Date of Birth
Child's Age
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School/Day Care Attended in the past school year. Please enter N/A if your child has not attended school or daycare in the past.
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Is your child currently receiving services from DTS?
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Yes
No
If your child is receiving therapy services from somewhere other than DTS, please indicate the service/s received and the clinic/provider name.
Does your child have a CURRENT (within the last 6 months) speech and language evaluation?
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Yes. (**Please upload a copy below if not completed at DTS)
No - I will need to have this completed by DTS.
No - I will have our current SLP complete an evaluation.
I will not be utilizing my child's insurance benefits. I understand that a current evaluation will be REQUIRED in order to file claims with my insurance provider and DTS/Camp Dynamics is unable to do this retrospectively.
Speech and Language Evaluation Report - File Upload
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Does your child have a CURRENT (within the last 6 months) occupational therapy evaluation?
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Yes. (**Please upload a copy below if not completed at DTS)
No - I will need to have this completed by DTS.
No - I will have our current OT complete an evaluation.
I will not be utilizing my child's insurance benefits. I understand that a current evaluation will be REQUIRED in order to file claims with my insurance provider and DTS/Camp Dynamics is unable to do this retrospectively.
Occupational Therapy Evaluation Report - File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Tell us a little more about your preschooler...
When would you like your child to attend Dynamic Days?
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Two days a week (9am-12pm)
Three days a week (9am-12pm)
Four days a week (9am-12pm)
Are you interested in extended day 8-9am and 12-2pm
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Yes
No
Does your child independently feed himself/herself?
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Yes - My child is FULLY independent with eating.
No - my child requires assistance.
Does your child independently use the restroom?
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Yes - My child is FULLY independent with all toileting needs.
Not yet but we are currently working on potty training.
No. We have not yet started potty training.
No. We have attempted to potty train but have not been successful.
Does you child nap? And how long usually?
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Is your child a danger to themselves or others?
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No. My child is NOT a danger to himself or others and has never been.
No. My child is not CURRENTLY a danger him/herself or others but has been in the past.
Yes we are currently struggling with aggressive, dangerous, and/or destructive behaviors with my child.
Does your child ever run away, hit themself or others, and/or throw things in response to being upset?
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NO - My child does not run away, hit themself or others, and/or throw things in response to being upset and never has.
YES - My child has in the past run away, hit themself or others, or thrown things in response to being upset. However, this is no longer an issue.
YES - My child does run away, hit themself or others, and/or throw things in response to being upset.
None of these responses fit my child's current or past behaviors. I would like the opportunity to discuss this question.
Please describe your child's STRENGTHS
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Please describe your child's CHALLENGES
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What are your primary goals for your child that you would like to discuss to determine if these are goals that can be addressed during the Dynamic Days Intensive Therapy Program?
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Anything else you want to tell us?
Insurance Information
In order for us to provide you an estimate of your financial responsibility, we must verify your insurance information. Including that information here allows us to do that before reaching out so that we are better prepared to answer your questions regarding cost to attend our Dynamic Days Intensive Therapy Program.
If you will not be utilizing insurance coverage, please write private pay below.
Insurance Carrier
Policy Number
Policy Holder's Name
First Name
Last Name
Policy Holder's Date of Birth
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Month
-
Day
Year
Date
Customer Service Number on Back of Insurance Card
Please enter a valid phone number.
Thank you for taking the time to provide this information!
Our Intake Specialist will be in touch with you shortly.
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