Full Name
Phone
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Email
*
What are the names and ages of the individuals seeking therapeutic services?
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How did you hear about our therapeutic services?
Can you briefly describe your family's current situation and any challenges you are facing?
What specific areas or issues are you seeking assistance with?
What are your primary goals and desired outcomes from therapy?
How do you envision therapy benefiting your family and supporting your child(ren)'s development and well-being?
What are your expectations regarding the intensive experience?
What are your preferred days and times for therapy sessions?
Are there any scheduling constraints or considerations we should be aware of?
Who else is involved in your child's life and can provide support (e.g., teachers, family members, caregivers)?
Are there any specific professionals or individuals with whom you would like us to collaborate or communicate?
Are you seeking out-of-pocket payment options or exploring any financial assistance programs?
Is there any additional information you would like to share or any specific questions you have for us?
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