Neuro-Intensive Therapy Screening Form

Neuro-Intensive Therapy Screening Form

At Bright Beginnings, we use a specialized neuro-intensive approach that integrates advanced neuro-therapy and low-level laser therapy to support brain function, regulation, and developmental progress. By completing this form, you’re taking the first step toward helping us understand your child’s unique needs and challenges.
Parent's Full Name

First NameLast Name
Patient's Full Name

First NameLast Name
Patient's Date of Birth

MonthDayYear
Date
Contact Number
Please enter a valid phone number.
Email Address
example@example.com
Where are you traveling from?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Tell us about you or your child's current challenges, strengths, and what you hope to achieve through therapy at Bright Beginnings.
I am Interested in

Intensive Therapy (week long programs)Virtual Home Program - with laserVirtual Home Program- without laserIntensive Consultation (One Hour)Gaining more information about Intensive Therapy programs
Our program represents a significant investment of time, energy, and financial resources ($365 per hour)- this level of care, committed therapists, advanced technology, and individualized approach that we provide are designed to create transformational progress and lasting results. I understand that this is a significant investment in my health. Are you prepared to commit to our Intensive therapy investment?
Additional Information:

We’re honored to partner with families who are ready to take meaningful steps toward lasting progress.If you have any questions, please visit our Q&A page at www.brightbeginningsptsj.com for more information about our programs, process, and approach.You can also connect with us on Instagram @brightbeginningsptsj to see parent reviews, success stories, and updates from our clinic.
By checking this box, I consent to receive communications from Bright Beginnings Pediatric Therapy via email and/or text message. I understand I can opt out at any time.
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Neuro-Intensive Therapy Screening Form

Additional Information: