Name of person completing this form: *

Email *

Phone/Video Phone (VP) *

Please provide the following information:

Select the role that most closely describes you: *

Parent/guardian

School-based professional (teacher, therapist, administrator, etc.)

Early intervention provider

Medical or allied health professional

Other (Please describe)Other (Please describe)

What services are you requesting from The Clinic? (Check all that apply) *

Direct services for a child/student (assessment and/or therapy)

Support for a family or team (school-based or medical)

Training, consultation, or workshops

I'm not sure

OtherOther

Please briefly describe your reason for seeking services *

Request Services