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/

Yes

Service Requested *

Speech-Language Therapy

Occupational Therapy

Physical Therapy

Developmental Therapy

Functional Vision Assessment for CVI

Neurodivergent Peer Connections Group

Outdoor Therapeutic Playgroup

Parent/Caregiver Support Group

Parent/Caregiver Respite Group

Other:

Required

Address *

Main Areas of Support/Priorities *

Is your child currently receiving therapy services? *

Yes

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?

Yes

Other:

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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? *

Send me a copy of my responses.

Submit

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