Preliminary Information Form

After receiving your information form, we contact you by email and set up an appointment to talk.

  General Information
Child's Name
Birth Date
Parent's Name
Parent's Phone Numbers
Best times for us to call you?
Parent's Email
Where are you located?
  About Your Child
Tell us about your child's situation.
Please mark all of the diagnoses your child has already received.
Autism Asperger's
PDD-NOS High Functioning Autism
ADD/ADHD Auditory Processing Disorder
Dyslexia Learning Disability
Dyspraxia Developmental Disability
Apraxia Developmental Delay
Dysgraphia Global Developmental Disorder
No testing Tested, no diagnosis
  VOIP Services you have
Please mark either of these free, Internet VOIP services you have available at home for us to use to talk with you, and available for us to use in our work with your child (learn about them).
Yahoo Messenger
None, but could install free software
None, and cannot install at home

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Last Updated: Sunday, December 16, 2007 08:06:50 -0200


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& Blogs

  Our Blog
Developmental Checklist  Our Free Membership Site
Our Information Form About Us
SelfGrowth Developmental Discovery
Systemô Consulting

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