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Intake Form
Please provide as much information as you are willing to share to assess prior to contact. Please reach out to
operations@andwalkendeavors.com
for additional assistance.
Client Name
*
Age/DOB
*
Language
*
Client Preferences
*
Medical Background
*
Information on Motor Skills
*
Maladaptive Behaviors/Behaviors of Concern
*
Current Interventions Provided (i.e. Occupational Therapy, ABA, Speech, Day Program, etc.)
*
Is the individual a client of a regional center?
*
Submit
