Child's Info

Name

First Name

Last Name

Gender

Date of Birth

YYYY

Adult's Info

Parent or Guardian's Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Tell us about your Child

Check any known histories in the child's immediate family

Speech/Language Delay

Learning Disabilities

Autism/PDD

Hearing Loss

ADHD

What is your child's primary language?

Is he/she exposed to other languages?

What are your child's interests?

What are your child's likes/dislikes?

Please describe your child's personality

Concerns

What are your current concerns with your child?

Please describe any occupational, physical, or speech and language therapy services your child is receiving or has received in the past.

What specific skills or milestones would you like to see your child achieve?

Does your child attend childcare or preschool? If so, where and how often?

Prior to attending playgroup at Thread's for Therapy, Build Learn Thrive staff will conduct a short parent interview.

How did you hear about Threads For Therapy?

Are you interested in hosting a clothing drive?

What are some ways you can help spread the word about Thread's for Therapy?

IG/FB/Twitter Name?

Do you give permission to Threads for Therapy to use photos of your child for reuse related to Thread's for Therapy?