OVERVIEW

Filll out the form below and click submit when completed.

Are you inquiring about: A Child
Certification Classes
Parenting Classes
Other
Instructions: Choose one the above and then fill out the corresponding answers in the related field below.
A Child:
Does your child (or the child that you are inquiring about) have a specific diagnosis? Yes
No
If yes, what is the diagnosis?
Is your primary concern: Physical( Gross motor/Fine motor)
Language/communication
Cognitive/Mental
Social
Feeding
Nutrition
Toileting
Other
Have you inquired or received assistance before? Yes
No
If yes, what services or assistance have you received before and did it help?
What is your specific question or concern?
What programs would you like to see?
Certification Classes:
Which Class are you most interested in? CIMI
CIIT
Other
Have you taken certification classes before? Yes
No
Are you a professional: Health Care
Child care
No
What classes or programs would you like to see?
Parenting Classes:
Which Class are you most interested in? Hanen
Infant massage
Nutrition
Mommy and Me
Other
Have you taken parenting classes before? Yes
No
What classes have you taken before?
What classes or programs would you like to see?
Contact:
What is the best way to contact you? Telephone
Email
First Name:
Last Name:
Email:
Telephone:
How did you hear about us?
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