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Your Information

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Address

Child's Information

Name:

Primary Diagnosis

Primary Mode of Communication:

Behavioral & Emotional Needs

Does your child have any specific behavioral needs or challenges?
Is there a specific approach or technique that works best for managing behaviors?
Does your child experience emotional distress or anxiety in certain situations?

Assisted Devices & Mobility Needs

Does your child use any assisted devices?

Sensory Concerns

Does your child have any sensory sensitivities?
Does your child engage in any sensory-seeking or calming behaviors?

Dietary Needs & Allergies

Does your child have any dietary needs or restrictions?
Does your child have any known food allergies or sensitivities?

Additional Information or Special Requests

Payment Details

February Hangout
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