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Child Intake Form

The following information will be kept in your child’s confidential file. Please feel free to add any information you think will assist me in helping your child and developing a good understanding of his/her needs.  Please complete the form as completely as possible and hit "submit" at the end.  The form will be securely emailed to me.

Child's Name *
Child's Name
Date of Birth
Date of Birth
Enter child's date of birth
Address
Address