Parent Information

First Name:

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Last Name:

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Address 1:

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Address 2:

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City:

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State:

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Phone Number:

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Email:

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Applicant Information

Child's First Name:

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Child's Last Name:

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Age:

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Program Information

Has your child been evaluated by a Neurodevelopmentalist (ND)?

No, my child has never had an ND evaluation and I am requesting the initial eval ($625).
Yes, my child has been evaluated by an ND and I am requesting a follow-up appt ($475).

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If you are requesting a follow-up appointment, please provide the date of your last eval.

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What are the areas you are most concerned about?

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I have attended a training by Kay Ness.
I have listened to Kay's "Audio Seminar' explaining the ND Program.
I have not attended training or listend to Kay's seminar..

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If you have had a previous evaluation please answer the following questions.

In what ways has the program benefitted your child?

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What areas do you feel you need the most assistance with?

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How many days per week on average are you able to work on any part of your program plan?

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Which specific activities do you find easiest to implement?

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Do you have a therapist or tutor assisting you in implementing this program plan?

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Scholarship Amount

Please let us know the scholarship amount required. You can request any amount necessary for your family to participate in the clinic. It is not guaranteed you will receive the full amount requested. It is our goal to allow as many families as possible to participate so we will do our best to accomodate every need. Please take into consideration if you can afford to pay for a portion of your evaluation, that will allow another family the opportunity to participate.

I do not need a scholarship.
I need a partial scholarship.

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Requested scholarship amount:

If you do not need a scholarship please enter 0.

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Other Information

Comments:

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I am a member of The Foundation.

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Neurodevelopmental Scholarship Application

Parent Information

Applicant Information

Program Information

Scholarship Amount

Other Information