Interested in any of our programs or services? Fill out the form below to contact our team! Step 1 of 3 33% Contact InformationYour Name* First Last Email* Phone*How do you prefer we contact you?*by emailby phonephone and/or email Program InterestWhich of our offered services are you interested in?*Early Intervention Services (Up to 5 years old)Over 6 Social Groups (6 years and older) Information about ChildChild's Name* First Last Child's Age*123456789101112131415161718Do you have more than one child you are interested in enrolling? No Yes Child's Name First Last Child's Age123456789101112131415161718Does your child have an ASD Diagnosis? Yes No On Waitlist for Assessment Current Method of Communication* Non-Speaking with no other forms of communication Non-Speaking - Uses another method of communication (like Touchchat, ASL, coreboards, iPad app, etc) Some speaking Speaking Current Toileting* In diapers/pull-ups In diapers/pull-ups - but we are looking to potty train In diapers/pull-ups - but we are currently potty training underwear - we are currently potty training Independent in this skill What are some of your child's interests and strengths?*What are some stretches (things that are difficult) for your child?*
