Intake List
Fill out this form in order to get on our waitlist for an intake assessment. We are currently at capacity and will not be conducting intakes for at least 3-6 months. Our program director will call you when we have an available space to schedule a free 15-30 minute intake.
Your name *
Date *
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Your email address *
Your phone number *
Your child's name *
Your child's date of birth *
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Location of services (please note, we do not provide home services) *
Preferred time of day (please note, we are closed on the weekends) *
I am in interested in the following services (check all that apply): *
Required
How does your child currently communicate? *
Please provide a brief description of your goals. *
Thank you for completing this form. Our Program Director will be in touch to schedule an intake assessment. *
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