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How old is your child?
Infant (0-1)
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Are you the primary caregiver for this child?
Yes
No
Do you currently live with this child?
Yes
No
Where are you located?
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Has your child ever been diagnosed with a condition or disability?
Yes
No
To the best of your knowledge, what was the event that caused the condition/disability?
Acute/traumatic injury
Illness
Congenital condition
I’m not sure
Are you interested in preschool or medical rehabilitation services?
Preschool
Medical Rehabilitation
Both
I’m not sure
What are you hoping to address through our care?
Pain, motor function, or mobility
Emotional/behavioral challenges
Problems completing daily routines
Issues with schoolwork/education
Struggles with speech
Difficulty interacting with peers
Struggles with memory/concentration
Other (please specify)
What other types of challenges are they facing?
Do you have a reliable and consistent means of transportation?
Yes
No, I would need assistance
I’m not sure
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