Request Services

Name of person completing this form: *

Select the role that most closely describes your interest in seeking services from The Clinic at CCCBSD: *

I am a parent/guardian looking for services for my child.

I am a school-based professional interested in services for a student.

I am an early intervention provider seeking services for a young child and/or family.

I am a medical professional or allied health professional interested in referring a patient/client.

I am a professional seeking consultation or training services for my district, school, or organization.

Other (Please describe)Other (Please describe)

Please provide the following information:

Email *

Phone/Video Phone (VP) *

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

Psychological/Neuropsychological services

Speech, Language, and Communication services

Educational (Teacher of the Deaf or Special Education) services

Reading/Literacy services

Behavioral assessment

Family support services

Consultation or training services

Reason for seeking services *