Application for REACH Home Program Initial Appointment
Please check all boxes that apply to your child
Vision *
Required
Reading *
Required
Hearing *
Required
Understanding *
Required
Tactile Ability *
Required
Muscle Tone *
Required
Mobility *
Required
Gross Coordination *
Please rate coordination on scale of 1 to 6
Very Poor
Excellent
Balance *
Please rate balance on scale of 1 to 6
Very Poor
Excellent
Language *
Required
Manual Ability *
Required
Writing *
Required
Behavior *
Please rate behavior on scale of 1 to 6
Very Poor
Excellent
Social Skills *
Please rate behavior on scale of 1 to 6
Very Poor
Excellent
Seizures/Absences *
Has had or currently has seizures/absences
Required
Health *
Rate health on scale of 1 to 6
Very Poor
Excellent
Child's Full Name *
Your answer
Child's Date of Birth *
Day/Month/Year
Your answer
Child's Diagnosis *
Your answer
Parent 1 - Full Name *
Your answer
Parent 1 - Address *
Your answer
Parent 1 - Telephone Number *
Your answer
Parent 1 - Email Address *
Your answer
Parent 2 - Full Name
Your answer
Parent 2 - Address
Your answer
Parent 2 - Telephone Number
Your answer
Parent 2 - Email Address
Your answer
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