Therapy Intensive Interest Form
Thank you for your interest in therapy intensives with Lemon City Collective! Please fill out this form to provide us with more information, and we will reach out regarding intensive availability. Thank you.
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Name of Person Completing this Form *
Relationship to Patient *
Email *
Phone Number *
Address *
Patient's First Name *
Patient's Last Name *
Patient's Date of Birth *
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Patient's Diagnosis (if any) *
Does the patient currently receive any therapies? Please describe *
What are you interested in working on during a therapy intensive? What specific goals would you like to achieve? *
How many weeks of intensive are you interested in completing? 
 *
What is your expected funding source? *
Required
Does the patient have insurance? If so, what insurance provider?  *
What dates are you interested in doing a therapy intensive at Lemon City Collective? *
Is there anything else we should know? 
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