Intake form

Name *

Email address *

Child's age

Disability diagnosis

Please select at least one option.

Autism Spectrum Disorder

Cerebral Palsy

Down Syndrome

Attention Deficit Hyperactivity Disorder (ADHD)

Learning Disabilities

Sensory Processing Disorder

Physical Disabilities

Preferred method of contact

Is your child currently receiving any therapies?

If yes, please specify the types of therapies received

What services are you interested in?

Please select at least one option.

Therapeutic services

Educational support

Life-skills training

Social skills development

Family support services

How did you hear about us?

Additional questions or comments

Echoes of Washington