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*
ZIP Code*
Primary Language Spoken in the Home
Relationship to the Child
Child's First Name*
Child's Last Name*
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?