Name of Parent/Guardian * First Name Last Name Date to Book Intensive * June 3 to June 21: 3 week June 24 to June 28: 1 week July 8 to July 19: 2 week July 29 to August 16: 3 week August 19 to August 30: 2 week September 9 to September 27: 3 week October 7 to October 11: 1 week October 21 to November 8: 3 week November 11 to November 22: 2 week December 2 to December 20: 3 week If you want to book more than one Intensive, please place additional intensives dates here (not guaranteed) Email * Phone (###) ### #### Name of Child * First Name Last Name Patient Age * Patient's Birthdate * MM DD YYYY Diagnosis Patient Weight * Patient Height * Patient's Current Gross Motor Skills * Goals Working On Currently * Any DMI Experience * Current Therapies * Comfortable with Therapy Dog present? Where did you hear about us? Any Message to Send to Us * Thank you for your intensive interest. We will look over your information and get back to you in a timely manner.
