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Online Registration Form

  1. If you are ready to request therapy, please fill out and submit the online registration form below.

  2. Then we will contact you.

  3. If you do not hear from us within 5 business days, please contact us to follow up.

Privacy Notice (Read only)

This is a standard privacy notice and is for your information only. You do not need to print this out. 

You will be asked if you agree to the information in this notice when you fill out the registration form.

Pediatric History Form (3 pages)


This on-line form will be sent to you by encrypted email to maintain confidentiality, to be returned to us no later than a week before your evaluation visit.

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