Complimentary Assessment

To receive a complimentary assessment, please complete the form below. After receiving the information, we will contact you to discuss the particulars of your situation and answer any questions you may have. If you determine that this program may be beneficial for you (or your child) and would like to visit our office, we will be happy to schedule an appointment. The Individualized Sensory Program is the first intervention of its kind in the country that can be custom-tailored to meet the particular needs of each individual.

If you prefer, your free assessment can be given over the telephone, or you may visit the center and speak to a member of our staff.

We respect your privacy. All information will be kept in strict confidence.

Assessment Form


Location:



Name:


Street Address:


City, State, Zip
,

Daytime Phone:


E-Mail:


Name of Child:


Child's Date of Birth:


Child's Gender:


Please provide us with a brief history. Include any relevant information regarding pregnancy, birth, birth defects, serious illnesses, surgeries, diagnoses, and any current medications: