Name * First Name Last Name Email * Phone * Your Child's Full Name * Patient's DOB * MM DD YYYY Why are you seeking our services? * * Has your child received a diagnosis? If, yes, please share it. * What other therapies have you tried? Occupational therapy Speech therapy Physical therapy ABA therapy Chiropractic Physiotherapy Neurologist Psychologist Other None What are you hoping to improve or see change in your child? * Are you interested in an intensive therapy program (1-3 weeks, 2-3 hours per day) * Yes No Not sure yet, I would like more information I consent to receive occasional educational communication from Brainshape Thank you!
