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Feeding Group Interest
Please fill out this form if you are interested in our Feeding Group at CTC!
We are currently providing this group on Thursday's from 5:00 PM - 6:00 PM
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Email
*
Your email
Child's Name
Your answer
Child's Date of Birth
MM
/
DD
/
YYYY
Guardian Name
Your answer
Phone Number
Your answer
Current Patient?
Yes
No
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Insurance Carrier?
*
Your answer
Child between ages 3-7?
*
Yes
No
Can the child separate from their adult with minimal assistance?
*
Yes
No
Can the child sit briefly?
*
Yes
No
Are you availabe on Thursdays between 5:00-6:00?
*
Yes
No
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