Post Early Intervention Functional Development Program Form
Please complete this form with the most current information.  The office will contact you to complete registration. Please contact the office with any questions or concerns. info@sandralthompson.com or (804) 683-2965. Thank you.
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Email *
Parent's name, address and phone number *
Name of Student *
Student's Current Grade/Age *
Does your child have a developmental development diagnosis? *
Did your child participate in an early intervention program?
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Did your child participate in a preschool program?
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Does your child have an IEP or 504? *
Does your child have a behavior plan? *
Describe your child's academic challenges and your areas of concern. *
What is your child's overall outlook about learning/academics? *
Does your child have any maladaptive behaviors toward self or others related to engaging in nonpreferred activities, being given instruction or attention impulsive seeking. If so, please describe. *
What skills would you like us to focus on? *
What are some of your child's interest? *
How soon would you like to start services? *
How many session per week? *
What times of day would work best for your child to be most attentive? (Please select at least two option). *
Required
Please share any information that will be helpful for us to better support your family. *
How did you hear about our services? *
If you were referred, please share their name. Thank you.
Photography Release 

Sandra L Thompson & Associates (SLT&A) has my permission to take and use photographs/videos of my child publicly to promote the program. I understand that the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fees, or other compensation shall be because of such use.
*
Name of person, address and phone number responsible for payment. *
I understand support received from Sandra L. Thompson & Associates is not covered by insurance. I will be responsible for out of pocket payment. Session are $50 per session. *
I give Sandra L Thompson & Associates permission to contact to me and complete my registration for services. *
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