Request an Evaluation/ScreeningPlease 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:* MM slash DD slash YYYY Gender Male Female Which 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?