Booking An Assessment At Kwanda Kinetics
Thank you for completing this short form.  The information in this form will help us to contact you with more information regarding our assessments as well as possible dates that we currently have available to perform an assessment at our practice.  We are looking forward to hearing from you!

PS.  If you are a school, teacher or other professional that would like to refer a child to us for an assessment, please contact us directly by sending an email to marene@kwandakinetics.co.za or phone Marene Jooste at +27 (0) 79 528 5076.  Thank you for your referral!
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Name & Surname Of Parent *
Cellphone Number *
Email Address *
Name & Surname Of Child *
Age Of Child *
Areas Of Concern And Reason Requesting An Assessment *
Is Your Child Currently Attending One Of Our Programs Or Are You A Private Patient? *
Area Where You are Currently Residing *
Do You Have A Whatsapp Account ? *
If So, Do We Have Your Consent To Communicate With You Via Whatsapp To Inform You When An Email Has Been Sent Regarding The Assessment ? *
Do You Prefer Communicating Via Emails Or Whatsapp? *
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