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?*Consultation Services (our Family Systems Consultant will come to your home to help you set up supports for your child to address their needs)Early Intervention Services (Up to 5 years old)Over 6 Social Groups (6 years and older)Over 6 Individual Sessions (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 Age123456789101112131415161718Current 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 for your child?*
