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SECURED KIDS CARE
Intake form
Help us serve you better
Name
*
Email address
*
Child's age
Child's gender
Select
Male
Female
Non-binary
Prefer not to say
What type of disability does your child have?
Please select at least one option.
Autism Spectrum Disorder
Cerebral Palsy
Down Syndrome
Attention Deficit Hyperactivity Disorder (ADHD)
Learning Disabilities
Please describe any specific needs or concerns for your child
Is your child currently receiving any therapies or services?
Select
Yes
No
If yes, please specify the type of therapies or services
Preferred method of contact
Select
Phone
Email
In-person
Address
Emergency contact name
Emergency contact phone number
Preferred appointment time
Select
Morning
Afternoon
Evening
Which service or services are you interested in?
Please select at least one option.
Individualized therapy
Support groups for families
Adaptive skills training
Initial consultation for $150
Follow-up consultation for $100
Additional questions or comments
Submit
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