Request Evaluation Request Evaluation 1 General Info2 Concern General InformationChild's NameDate of BirthAddressParent/Guardian NamesInsured's Name and Date of BirthHome PhoneCell PhoneE-mail Address Is there any known history of the following in the immediate or extend family? Autism/PDD ADHD Learning Disabilities Hearing Loss Stuttering Speech/Language Delays Concerns1. When did you first have concerns about your child?2. What made you concerned?3. What Strategies or techniques have you been trying independently?4. What is your primary concern today?5. What specific skills would you like your child to achieve in therapy?CAPTCHA
