Already had an Evaluation? If you already had an evaluation completed from another therapy service provider, please use This Form Here .

Preliminary Online Screening: This is not an official screening, as this would have to be scheduled and performed in person.

Use this form so we can better understand your needs prior to scheduling the initial FREE screening.

Your Name (required)

Your Email (required)

Phone number:

Who is requesting? (your relationship)

Gender (receiving therapy):

Date Of Birth:

Requesting what type of therapy?

Name of City therapy recipient resides in:

Name of School they are attending (if any):

Select all that apply with one requiring Therapy:

Executive functions --Cognitive ability --Speech disorder --Language impairment --Reading disorder --Autism --Dysarthria --Dysphasia --Attention Deficient --Behavior issues

Your insurance provider: (enter private for private pay)

Were you informed that therapy is needed? If so by whom? (school, Doctor, etc, or enter NO)

Was there any prior therapy received?

This is the most important part. Please briefly describe what you are seeking, desiring and what you are observing that you believe therapy is needed.

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