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Form of initial reception
Information about parents/guardians:
Name:
*
Last name:
*
Contact number:
*
E-mail:
Information for the patient
Name:
*
Last name:
*
Date of birth:
*
Gender:
*
-
Man
Woman
Current diagnosis (if any):
*
Purpose of child's arrival/needs:
Behavior correction
Speech and language development
Psychological help
Development of motor skills
Academic support
Socialization and communication skills
Another
Therapeutic or educational programs in which the child has previously participated:
Current medication (if any):
How many times a week would you like to participate?
*
-
1 session
2 sessions
3 or more
Intensive program (5 days a week or camp)
Additional notes or questions:
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