Information Request Form
Parent/Caregiver Name
*
First Name
Last Name
Child's Name
*
First Name
Last Name
Child's Date of Birth
-
Month
-
Day
Year
Date
Caregiver Email
*
example@example.com
Caregiver Phone #
*
Please enter a valid phone number.
Interested In:
*
Please Select
Infant Feeding Therapy (0-6 months)
Pediatric Feeding Therapy (6 months+)
Myofunctional Therapy
Location
*
Hollywood
Ft. Lauderdale
Aventura
North Miami Beach
Other
Zipcode:
*
My child has the following symptoms (click all that apply):
*
Bottle/Breastfeeding Challenges
Picky Eating/Texture Aversion
Oral Motor Weakness/Drooling
Tongue/Lip Ties
Starting or Progressing through Solids
Faliure to Thrive
G-tube/n-g tube transition
Myo: Thumb Sucking
Myo: Sleep Disordered Breathing
Myo: Drooling
Myo: Open Mouth Breathing
Myo: Tongue Thrust/Lisps
Other
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Price List Information
We are a boutique concierge private practice and we come to YOU! We currently are traveling in the following locations: Ft. Lauderdale [Davie, Plantation, Pembroke Pines], Hollywood, Aventura, and North Miami Beach. There is a weekly travel outside of Ft. Lauderdale/Hollywood.
Feeding Therapy Price List
Myofunctional Therapy Price List
You are aware that we are an out-of-pocket out-of-network provider, accept Step Up's FES-UA Scholarship & FSA/HSA Payments.
*
Yes
I plan to use my FES-UA Scholarship for payment (3 years old +)
*
Yes
No
Interested in:
*
Please Select
Complimentary Consultation Call Before the Evaluation
Schedule Evaluation ASAP
Complimentary Consultation Call Only
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