Discuss Your Child’s Treatment Options New Client Information Child's Name* First Last Child's Birthday* Date Format: MM slash DD slash YYYY Services Required* Speech Occupational Therapy Physical Therapy Other Other ServicesParent's Name* First Last Email* Enter Email Confirm Email Referred By?* Google/Internet Yelp Parent/Friend Professional/Medical Education/School Other Referred ByPhone*SchoolDate of walk-in/initial call: Date Format: MM slash DD slash YYYY InsuranceDiagnosis?ConcernsPreviously Assessed Before? Yes No Currently Receiving Any Other Services? Yes No What Kinds of Services and Where?Does Your Child Have an IEP?* Yes No Availability: School Hours?Availability: Nap Time?Availability: Extracurricular Activities?