Parent/Caregiver Name *

First Name

Last Name

Child's Name *

First Name

Last Name

Is Your Child Experincing Any of the Following? *

Please check all that apply.

Attention Deficit Hyperactivity Disorder (ADHD)

Autism Spectrum Disorder (ASD)

Sensory Aversions

Dressing/Grooming/Bathing Difficulties

Physical Limitations

Clumsiness or Difficulty with Coordination

Poor Handwriting

Feeding and/or Picky Eating Difficulties

Speech and Language Difficulties

Poor Social Skills

Physical Injury/Sports Related Injury

Other Developmental Delay