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Application

Application Form

If you are unsure of  your child’s symptoms, ask them the following questions. If there is a reply “Yes” to more than half of these questions please fill out an application form. (These question are coming directly from Nemours Children’s Health)

• • Does my child often mishear sounds and words?
  • Are noisy environments overwhelming when my child is trying to listen?
  • Does my child’s listening behaviors and performance improve in quieter settings?
  • Does my child have trouble following verbal directions, whether simple or complicated?
  • Does my child have trouble with spelling or phonics?
  • Are verbal (word) math problems hard for my child?
  • Are conversations hard for my child to follow?

• If you notice that your child has any symptoms of Auditory Processing Disorder (APD) or Visual Processing Disorder (VPD), feel free to fill out the application below to acquire access to some of our therapists!  Our therapists can help with mitigating APD and VPD symptoms to help your child perform better in general. If there is already a potential therapist you have in mind please mention it in your application.

Application Form

Child Name *

First

Last

Gender *MaleFemaleOther

Date of Birth *

Current School *

Current Address (Street Address) *

City, State *

Zip Code *

Primary Insurance Carrier *

Name of Legal Guardian 1 *

First

Last

Occupation *

Relation to Child *

Gender *MaleFemaleOther

Phone Number *

Email *

Name of Legal Guardian 2 *

First

Last

Occupation *

Relation to Child *

Gender *MaleFemaleOther

Phone Number *

Email *

Please describe your child’s specific needs/areas of concern. *

How did you become aware of your child’s special needs? *

Is there anything else you would like us to know? *

Submit