NEW CLIENT INTAKE FORM
Welcome to WildWorks Therapy, formally known as Debbie's Playce! We are excited to work with you and your child and/or children to get the therapy and results necessary. We treat children with developmental delays, sensory processing difficulties, fine motor challenges, and behavioral and mental health disorders. We work very hard to get you and your child the best results for a healthy, happy, and successful life. We believe in family-centered care and ask that you participate in our therapy sessions as much as possible.

As part of our services, you will receive a 15-minute weekly phone session, or as needed, to answer any questions you may have about your child's therapy sessions. We thank you for choosing us and we are excited to begin the journey to success with you and your child!
Child's First and Last Name: *
Child's Date of Birth: *
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Child's Primary Language: *
Legal Guardian's First and Last Name (1): *
Relationship to the Child: *
Required
Phone number: *
Email address: *
Home address (including City, State, Zip): *
Legal Guardian's First and Last Name (2):
Relationship to the Child:
Phone number:
Email address:
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