Intake
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Name
 *
Email *
Child's full name:
 *
Child's Date of Birth (MM/DD/YYYY)
 *
Mailing address:
City/Town/Zip Code:
Phone Number:
 *
Child's School District:
 *
What grade is your child in currently:
 *
Name of school your child attends:
 *
Presenting Problem:
 *
Does your child have
Has your child ever been evaluated for a learning/developmental disability?  If yes, who did the evaluation(s)?
Was your child evaluated:
 *
Required
How can I help you and your child today?
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