Child's Name *

First Name

Last Name

How does your child best communicate? *

with words

a combination of words and gestures

a combination of gestures and facial expressions

with physical movement or touch

with pictures or a device

My child currently receives *

(Please provide additional info for therapy received below.)

Speech therapy

Occupational therapy

Physical therapy

Behavioral therapy

None of the above

Does your child have any food allergies? *

Yes

No

Would you like a 30-minute consulation with one of our therapists prior to starting an Outdoor OT Group for $65? *

Yes

No