Request an Evaluation/Screening Please call us at 424-331-9212 to schedule an evaluation, or fill out the form below and we will contact you as soon as possible. Parent/Guardian First Name:*Parent/Guardian Last Name:*Phone Number:*Email Address:* Street Address:*City:*State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZIP Code:* Primary Language Spoken in the Home:Relationship to the Child:Child's Name: First Last Date of Birth:* Date Format: MM slash DD slash YYYY GenderMaleFemaleWhich services are you interested in?* Augmentative and Alternative Communication (AAC) Therapy Behavioral (ABA) Therapy Child Psychology and Counseling Feeding Therapy Infant/Toddler Services (e.g., delayed speech, fine motor, gross motor skills, torticollis, plagiocephaly) Literacy Occupational Therapy Oralfacial Myology (Tongue Thrust) Physical Therapy Sensory Processing Social Skills Group Speech-Language Therapy Transition to Adulthood Briefly describe your concerns.*Name of Pediatrician:Name of Pediatrician's Clinic:Pediatrician's Phone Number:Pediatrician's Fax Number:How did you hear about us? Physician Friend Web Search Teacher or Educator Advertisement Other If "Other," please specify.Is there anything else you would like us to know?