Sign up for a 15-minute free consultation / waitlist
MAGIS Therapies and Mindworks Neurofeedback Center is currently offering 15-minute free online consultations for those who need support and/or would like the opportunity to try Occupational Therapy.

For questions and/or clarifications, you may contact our team at:
magis.mindworks@gmail.com

To help us serve you in the best way possible, please provide the information below.

Please note that this is not a 24/7 hotline.
In case of emergency, or if you think your life or someone else's life is in danger, please call:
DOH-NCMH Hotline:
0917-899-USAP (8727)
0917-989-USAP (8727)
Or go to the nearest hospital within your vicinity.

All information provided is kept strictly confidential.

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Email *
What is your purpose for filling up this form? *
Please be informed that our occupational therapy slots are full as of the moment. If you wish to be immediately notified the next time an available time slot comes up, kindly choose “include my child on the waitlist”. 
Client's First Name *
Client's Last Name *
Client's Nickname *
Client's Age *
Client's Date of birth *
MM
/
DD
/
YYYY
Client's Gender *
Parent/Guardian's full name *
What is your relationship to the client? *
Client's Complete address *
Contact number *
Email address to contact: *
Description of the problem or general concern *
You may be as detailed as you wish. Kindly note as well if you have been given a diagnosis and when have you been diagnosed by a developmental pediatrician or a psychiatrist.
Are you aware of what could be triggering your child's concern? *
Please write what triggers your concern and/or when does it happen.
How long has this been a problem for you? *
Please write when did you think your concern has started and how long has it been an issue for you.
How often does your concern takes place? *
If the frequency doesn't match with the choices below, you may be as detailed as you wish by choosing "other".
Is your child taking any medications for your concern? *
Please enumerate the medications you are taking as of the moment, if there is any.
Has your child been diagnosed by a developmental pediatrician? *
If yes, what is his/her diagnosis? *
Have you sought therapy before? *
Please write the interventions your child did in the past.
When was the last time your child attended therapy? *
Please specify the month and year.
IN CASE OF EMERGENCY, PLEASE CONTACT:
To support you to the best of our capacity, please include an emergency contact.
Full name of emergency contact *
Emergency Contact's complete address *
Emergency Contact's contact number/s *
Emergency Contact's relationship to you *
ACKNOWLEDGEMENT
I certify that the information provided in this form is true. *
Required
A copy of your responses will be emailed to the address you provided.
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