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Email
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Your Name
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Your Child's Name
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Child's Age
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Child's Birthdate
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Your Phone Number
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Best Way to Reach You
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Email
Phone
Other:
Best Times to Reach You
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Services you are looking for from Touchstone
Developmental Behavioral Pediatric Care
Medication Consultation/Care
Neuropsychological Evaluation
School/Classroom Observation
IEP/504 Consultation (getting, keeping, changing IEP or 504 Plan)
Therapy
Parent support
WPPSI/WISC testing for private school admission
Not sure
Other:
Please share your current concerns
Anxiety
Attention/ADHD
Autism Spectrum Disorder
Behavior Problems
Depression
Dyslexia
Executive Functioning
Motor Delay
Other Learning Disability/Problems
School Problems
Social Skills
Other:
If your child currently receives IEP services, please share the services offered:
My child has no IEP
Applied Behavior Therapy (ABA)
Counseling
Occupational Therapy
Paraprofessional (one to one or shared aide)
Small Classroom
Special Education Teacher
Speech and Language Therapy
Not sure what services are on my child's IEP
If your child has had psychological or neuropsychological testing in the past year, where was it completed and when?
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What insurance do you have?
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Please let us know if you have specific questions or more to share with us!
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Who referred you for this visit?
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A copy of your responses will be emailed to the address you provided.
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