Request an Appointment

Parent's Name *

First Name

Last Name

Child's Name

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Services interested in: *

Speech-Language therapy

Occupational therapy

Feeding/swallowing therapy with an SLP (gagging, difficulty swallowing/chewing, choking)

Feeding therapy with an OT (sensory aversions, gagging while looking at/smelling/or touching food, avoiding based on texture)

Feeding groups

Social groups

Pediatrician's Name and Office *

First Name

Last Name

Funding Source *

Please note: We are not Medicaid Providers

Insurance Company

Jon Peterson Scholarship

Autism Scholarship

Self pay

Not sure