Therapy services Inquiry form
If you’re interested in exploring services for yourself or your child, please complete this form, and a Seeds of Learning team member will be in touch.
Prospective Client Name
*
First Name
Last Name
Prospective Client's Age
*
Person Filling Out This Form (if not the Prospective Client)
First Name
Last Name
Relationship to the Prospective Client
Email
*
example@example.com
Confirm Email
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Best way to contact you:
*
Email
Text
Phone call
Any of the above are fine
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What are your concerns? Check all that apply.
*
Speech
Language
Reading
Writing
Social development
Executive function (self-regulation)
Other
What concerns or challenges led you to reach out about therapy?
*
What mode of service delivery are you interested in?
*
In person
Virtual
First available
We typically complete evaluations during school hours and can provide an excusal letter if needed. Would this work for you and/or your child?
*
Yes
No
What is your or your child's availability for therapy? Check all that apply. Please note: Morning appointments are most likely to become available first.
*
Rows
Morning
Afternoon
Monday
Tuesday
Wednesday
Thursday
Please note that we are a private-pay practice and do not accept insurance or any third-party payer options. All services are billed directly to families, and a credit card is required to be kept on file for payment.
*
Yes, I understand
How did you hear about Seeds of Learning?
Please Select
Friend/Family/Colleague
Medical Professional
Education Professional
Social Media
Google
Other
Is there anything else you'd like us to know about you or your child?
Save
Submit
Should be Empty: