Behavioral Intervention English Program: Information Request
Please complete the information below. Once the information is submitted a Tuesday's Child representative will respond to you within 2 business days.

If you are interested in the Spanish language program, please call Letty Perez (773) 230-0227.
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Email *
Parent's First Name *
Parent's Last Name *
Home Address *
Home City, State & Zip Code *
Phone Number *
Please put the best number for Tuesday's Child to reach you.
Child's Name *
Child's Date of Birth *
Child must be walking and 6 years of age or less.
Present Concerns *
Why are you interested in attending the Tuesday's Child Behavioral Intervention Program?
How did you find us? *
If you were referred, please provide the name and address of the referring provider.
Does your child currently attend any school or programs? If yes, please include where and for how long *
When are you and your child available to attend Tuesday's Child? Behavioral Intervention group requires both parent and child attendance during your scheduled weekly time *
Please select all available choices.
A copy of your responses will be emailed to the address you provided.
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