The Floortime Center Intake Form
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Email *
Orientation: Please Watch
How did you hear about us? *
Required
If it was through a doctor, therapist, or the parent of a child, then please let us know who.  Write n/a for other sources.   *
Which Floortime Center are you closest to? *
Which director did you speak with at The Floortime Center? *
Child's Last and First Name *
Child's Diagnosis (Optional). If you are going to start therapy services with us, then we will need a diagnosis code to put on invoices for your insurance.
Todays Date *
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Child's Birthdate (please make sure the year is correct) *
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Address (include zip code) *
Parent 1 first and last name *
Parent 2 first and last name *
Parent 1phone number and additional email address *
Parent 2 phone number and additional email address *
How would you describe your relationship with your child? *
Parent 1: What are your favorite things to do with your child? *
Parent 2: What are your favorite things to do with your child? *
Parent 1: How much time each day do you spend one on one with your child? *
Parent 2: How much time each day do you spend one on one with your child? *
Describe your child's sleep patterns. Do they have trouble going to bed, staying asleep, waking up very early, etc.? *
How many playdates per week do they have? Don't include school. *
How much screen time do they get?  This includes phones, tablets, TV, computer, gaming systems, etc. *
What are you personally most concerned with? (Select all that apply) *
Required
Please describe these concerns further.
What therapies/supports is your child currently receiving? Please include any that you have been doing over the last 6 months even if you are taking a break. (Select all that apply) *
Required
What Greenspan Floortime-based services are you looking for? (Therapies are provided by highly trained Greenspan Floortime professionals) *
Required
Greenspan Floortime: Parents and caregivers agree to...
(Please read this article to understand the expectation in #3)
 *
We Agree
Each spend a minimum of 30 minutes per day doing floortime.
Listen and provide empathy and understanding with gentile but firm limits during daily routines and challenging behavioral moments.
Encourage my/our child to 'do the thinking' as much as possible.
Communication: Parents agree to... *
We Agree
Respond to our emails within 24-48 hours.
Provide us with feedback on a weekly basis.
Share with us any changes in life, at home, in school, or in therapy program.
Any requests or notifications about schedules/cancellations will be sent in writing via email.
Check the box below acknowledging that... *
Check the box below acknowledging that you have read and agree to our billing and cancellation policy. *
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