Email address *
Child's Name *
How old is your child? *
Father's Name *
Father's Phone Number *
Mother's Name *
Mother's Phone Number *
Alternative Email Id *
What is/do you suspect is the diagnosis of the child? *
When did you first notice any changes in him/her? *
Have you tried any interventions till now? Yes or No *
If yes, what interventions have you tried and for how long? If No, then write none *
Did you see any benefits or negative effects from the interventions you tried? Please list them? *
Intervention benefits negative effects/consequences
What type of diet do you give your kid? Have you tried any other diets and please list any benefits or negatives that you have seen with them? *
Diet benefits negative effects/consequences
Is there anything that weighs you down the most or stresses you the most? *
Is your child currently going to any school ? *
Please give details about his day at his current school, if he attends. Write none if he does not go to any school *
How did you come to know about PlayStreet ? *
PlayStreet School Program is for empowering Parents and it brings the most benefits to a child whose family works with us as a part of team. Are you willing to be a driver of the team where we are navigators ? *
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