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 therapy

Occupational therapy

Feeding/swallowing therapy

Social groups

Feeding groups

Pediatrician's Name and Office *

First Name

Last Name

Funding Source *

Insurance Company

Jon Peterson Scholarship

Autism Scholarship

Delaware County Board of Developmental Disabilities

Self pay

Not sure