Request for CHAT Services
You may enter your personal information here and a Family Dynamics CHAT Representative will contact you for an appointment. The information you enter is confidential, however as with any electronic systems, your information may not be secure. Select (I Agree) to indicated that you acknowledge the limitation of protection of your information.
I Agree *
Child's First Name: *
Your answer
Child's Middle Name:
Your answer
Child's Last Name: *
Your answer
Child's Birthdate: *
MM
/
DD
/
YYYY
Sex *
Child's Ethnicity
Optional, for demographic informational purposes only.
Name of Child's School
Your answer
Child's Grade level
Parent or Legal Guardian's Name *
Your answer
Street Address: *
Your answer
City, State, and Zip Code: *
Your answer
Email Address:
Your answer
Contact Phone Number: *
Your answer
Other Contact Phone Number:
Your answer
How would you like to be contacted? *
Required
Can we leave a message? *
If your child is currently under the care of a Physician, please state the Physician's name and contact number.
Your answer
Please list any prescription medication your child is currently taking.
Your answer
Do you or your child have any physical limitations?
Your answer
Source of Payment: *
Funding is provided for children (17 and under) who are determined to be eligible for the CHAT program. Please list any other sources of Payment you currently have.
Required
How did you hear about us? *
Required
Please check any and all that apply:
This is information about your child
Behavioral Questionnaire
The following questions apply to the child's behavior.
Has your child experienced or witnessed any of the following: *
Check any or all that apply.
Required
Has the child experienced a recent change in their life? *
Required
Is English your primary language? *
Can you read and write in English? *
If English is not your primary language, do you need an interpreter?
Do you need help with transportation for services? *
Office Use Only
Your answer
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