Your name

D.O.B

Email

Phone

Address Line

Concerns with Child's development and/or behavior

Child's Diagnosis (Pease circle all that apply):
AutismADHDAnxietyLearning Disability

Other (Display of one or more of the following behaviors /maladaptive)
StereotypesInability to stay organizedSelf-injurious behaviorsInterpersonal relationship dysfunctionAggressionRitualistic BehaviorsImpulsivityOppositional / Defiant BehaviorInattentionProperty DestructionTantrumsPICA/ MouthingHyperactivitySensitive to changeFailure to comply with instruction

Insurance (If known):
MedicaidMedicaid HMOPrivate Pay

Other

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Setting (choose one or more)
HomeSchoolCommunity

Availability (choose one or more)
MorningsAfternoonsEvenings

Other

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*Kindly submit all documents and or evaluations available.