Pediatric intake form

And recorded short videos of the child’s function

Please fill out this form so we can determine if your child is a candidate for our program. Additionally, we need to see 2-3 short videos (30 seconds or less) of your child’s function as applicable. To upload these videos, please use the link below.

Please record the following for each category:

Physical therapy:

• on the floor moving around by rolling or crawling
• standing with and without braces
• walking/running with and without braces

Occupational therapy:

• fine motor play
• using utensils for writing/drawing and eating

Speech therapy:

• child talking

Feeding therapy:

• eating/drinking

Please fill out our intake form: