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Form Intake

We have designed our program to be diverse and inclusive of all persons regardless of their age, race, creed, religion, gender, and/or gender identity. Our services will always be available to everyone in our community.

Client Intake Form

Client Intake Form

  • When completed, please send this intake form and a copy of the front + back of your insurance card.
  • Email to [email protected].
  • An administrator will confirm receipt of the document.
  • If you do not hear back from us within 48 business hours, please contact us by phone: 888-286-8715 ext. 6.
Is your child conserved?
(Number is on the insurance card)
You may include more than one.
You may include more than one.
Do you check email daily?
Preferred method of contact
Interested in services in school?
1-1 support provided in school?
Interested in receiving Speech or OT services at our clinic?
Pets - For home-based sessions, pets may have to be in a separate room
Safety risks in the neighborhood?
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