Request an Evaluation/Screening Please call us at 610-455-4040 to schedule an evaluation or fill out the form below and we will contact you as soon as possible. Your First Name*Your 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 HomeRelationship to the ChildChild's First Name*Child's Last Name*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 PediatricianName of Pediatrician's ClinicPediatrician's Phone NumberPediatrician's Fax NumberHow 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?