Therapy Services Interest Form
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Email *
Caregiver Name *
Caregiver E-Mail Address *
Caregiver Phone Number *
Child's Name *
Child's Age *
Child's Pronouns

 *
Will you be utilizing NCSEEA grant funds for services?

*for more information: https://www.ncseaa.edu/
 *
Service Requested *
Required
Address (please include street address, city/town, zipcode) *
Preferred Location of Services 
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Preferred Days for Services
Preferred Times - please specify days/times that work best for your schedule (i.e. Tuesdays or Thursdays between 10-2pm)
Main Areas of Support/Priorities *
Is your child currently receiving therapy services? *
If yes, which therapy services are they receiving and where?
Have you ever been unable to access services your child needed because they were too expensive?
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 How challenging is it for you (on a scale of 1 to 5, 1 = easy and 5 = very difficult) to find affordable and supportive services for your child? .
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What has been the greatest barrier to receiving services for your child?
How did you hear about us? *
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