Personalized Support- Parent/Caregiver Application

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Email *

Today's Date *

YYYY

Phone Number (include country code and, if applicable, area code) *

Name of Person Applying: *

Type of Caregiver *

Parent

Grandparent

Babysitter/Nanny/Au Pair

Other:

City and State Where You Live:

(If it is outside the US, then please share the Country and City.)

Child's Age *

Please describe your child's strengths. *

Please describe your child's challenges. *

If you have received some type of 'Floortime' support or training, whom was it with?
*

Stanley Greenspan MD Inc

ICDL

Profectum

N/A

Other:

Required

Please describe the extent of your training and include when it took place. (If you haven't participated in any, then please write N/A.)

Why do you want support for providing therapy within Dr. Greenspan's framework, The Greenspan Floortime Approach and the Greenspan/DIR Model? *

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