Milestones4Kids Intake Form
We are dedicated to providing comprehensive occupational and speech therapy services to children in Maryland, Virginia and DC. With a passion for empowering children to reach their full potential, we offer personalized care tailored to each child’s unique needs. Our mission is to empower children to thrive through personalized, compassionate therapy services, fostering confidence and independence every step of the way.
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Email *
Child's Full Name: *
Child's Date of Birth: *
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Child's Age *
Child's Grade *
Parent Responsible for Payment: *
Parent Cell Phone Number: *
Parent Email Address: *
Parent Home Address (please include street address, city, state and zip code): *
Parent Name (if different than above) who would like to receive paperwork to fill out / get session reminders:
Parent #2 Cell Phone Number:
Parent #2 Email Address:
Parent #2 Home Address (please include street address, city, state and zip code):
What school does your child attend? *
If there is any diagnosis, please share: *
If you would like an evaluation, what days/times is your child available for an evaluation? *
What days/times is your child available for weekly sessions? *
Reason for Referral: *
Would you like a full evaluation? *
Required
If yes:
Are you interested in our social skills groups?
Are you interested in our Travel Day Camp for this upcoming summer? *
Required
Who referred you to us / How did you hear about us? *
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