Refer My Child
*This Form is for children through age 18. If you are referring yourself or another adult, please click below to complete the adult referral form. 

Thank you for your interest in The Lark Center!
 
Please provide the following information about your child and a member of the team will reach out to you to schedule an appointment.
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Email *
Child's First Name *
Child's Last Name *
Child's Date of Birth *
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Child's Grade In School (if applicable)
Child's Gender *
Child's home address (street, town, state, and zip) *
Please list all languages spoken in your child's home(s). *
Please describe your child's strengths, interests, and/or temperament.  *
Please describe the concerns you have for your child. What is the reason for this referral? *
Please list any medical, behavioral, or academic diagnoses your child already has (if applicable) *
Has your child received any evaluation reports or treatment plans (IEP, IFSP, etc.) in the past 12 months? *
Required
Name of your child's school or daycare (if applicable) *
Please indicate your priority goal area(s) for your child *
Required
1st Parent/Guardian Name (first and last) *
1st Parent/Guardian email *
1st Parent/Guardian phone *
2nd Parent/Guardian Name (first and last)
2nd Parent/Guardian email
2nd Parent/Guardian phone
What is the best way for our intake coordinator to contact you? *
Intake appointments are typically scheduled Monday mornings and Tuesday afternoons. Please indicate your preference.  *
Required
What information are you seeking as a result of this intake appointment? Select all that apply *
Required
How did you learn about The Lark Center? *
Required
Is there anything else you would like us to know about your family or your child?
A copy of your responses will be emailed to the address you provided.
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