Request an Evaluation!

Your Name *

Name of person filling out this form

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

Your relationship to the child *

Parent, Guardian, or Foster Parent

Early Interventionist/Case Manager

Physician/Physician's Assistant/Nurse Practitioner

Other Therapist or Service Provider

Other (fill in below)

Contact Name *

Name of person to contact when an opening becomes available

First Name

Last Name

Contact Phone *

Phone number of person to contact when an opening becomes available

(###)

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Reason(s) for Referral *

Check all that apply

FINE MOTOR SKILLS (grasp, dexterity, ability to manipulate objects with hands, handwriting, cutting skills, etc.)

SELF-HELP/DAILY LIVING Skills (dressing, feeding, etc.)

SENSORY PROCESSING (Child's ability to take in sensory input and respond appropriately. Hypo- or Hyper-sensitive?)

BEHAVIOR/EMOTIONAL REGULATION

EXECUTIVE FUNCTION SKILLS (organization, memory, task initiation/completion, etc.)

My child was recently diagnosed with Autism and/or ADHD and our family needs some guidance on what to do next.

I or someone else in my child's life suspects that he/she may be on the Autism Spectrum or have ADHD and our family would like some guidance regarding pursuing a potential diagnosis.

Another service provider suggested I should look into OT for my child.

Other (fill in below)