Name of child * First Name Last Name Name of parent or caregiver * First Name Last Name Home Address * Email * Phone * Please note we ask for your number as a precautionary extra form of contact in case of accidental email issues (wrong address, spam, etc.) (###) ### #### Age of child * Weight of child * What functional motor skills does your child currently have? (e.g. can your child hold their head up, can they roll, can they sit, etc.) * Child's diagnosis * (if appropriate) Has your child ever completed an intensive and/or done DMI? * What services are you interested in? (Check all that apply) DMI Intensive Weekly DMI sessions Speech or Feeding Intensive Weekly Speech or Feeding Sessions Weekly OT Sessions OT Intensive How did you hear about us? * Thank you! We will get back to you as soon as possible. Contact Us Follow us on Instagram #RiseUp #RiseUp #RiseUp
