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Intake Form

*This form is for a request for services request. Please provide as much information as you can in the "Services Needed" area. This will allow me to get a better understanding of your needs prior to our appointment.

First name

Last name

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Services Needed

Provide details of the services you/your child require.

Disability Diagnosis

How did you hear about us?

By signing this document, I acknowledge the inherent risks and voluntarily assume full responsibility for any injury, damage, or loss that may result from my participation. I hereby waive and release the business, its owners, and its staff from any and all liability, past, present, and future, relating to the services provided.

Signature

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