Name of child * First Name Last Name Name of parent or caregiver * First Name Last Name Location * Are you interested in clinic or in home intensive? If in home, please write your 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? * 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
