Inquiry Form
Please complete the following questions so I may better understand your child's strengths and challenges to determine the right interventions to match your child's needs. Please note that the information you share below will be kept private and confidential per the United States HIPPA privacy standards. Information shared is accessible only by your occupational therapist, Dr. Elizabeth Joy Shaffer.
Please verify that you are human
*
What problem or challenge is your child or teen facing that you are seeking help for?
*
How much is this problem or challenge impacting their life now?
Not at all
1
2
3
4
Very much
5
1 is Not at all, 5 is Very much
Please check the types of services are you seeking for your child?
*
Occupational Therapy Evaluation
Occupational Therapy Interventions/Sessions
Life Skill Coaching
Personal Growth for Teens Group
What is your goal for interventions?
What have you tried in the past to help your child with this current problem or challenge?
Your Name
First Name
Last Name
Your Child's Name
First Name
Last Name
Your Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Child's Gender
Female
Male
Transgender
Gender neutral
Non-binary
Prefer not to say
Other
Age
City & Country
Do you have any additional questions, concerns, or thoughts you want to share?
Submit
Thank you
Within three days, you will receive an email to set up a time to discuss the next steps and have any additional questions you may have answered. If you have yet to receive an email from me within 3-days of completing this form, please check your spam folder or contact me by email at elizabeth@therapyintl.com. I look forward to talking with you.
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