Gross motor – Is your child able/unable to (please describe how much assistance your child needs for each activity or transition):
Fine motor – Is your child able/unable to:
Please describe the augmentative communication/assistive technology that has been previously tried, the length of time of each trial, and the outcome (how did it work, or why do you think it didn't work?).
What feeding problems is your child experiencing?
Please note, once the form is completed you will receive an email including a link to sign our terms and conditions. Your intake will not be reviewed until the terms and conditions have been signed.
I hereby authorize the NAPA Centre to use the photographs and video taken of myself or my minor child during the therapy/exercise sessions and any other activities or functions at NAPA Centre. The use of photos or videos by NAPA Centre through mass media, displays, brochures, websites, and other means of communication is strictly voluntary and is not paid for, endorsed, or compensated in any way. Authorization: I authorize the use and disclosure of my child's name, photographic/video images, and/or testimonial for marketing purposes by NAPA Centre Inc. I understand that information disclosed pursuant to this authorization may be subject to redisclosure and may no longer be protected by HIPAA privacy regulations. Purpose: The photographic/video images, and/or testimonial will be used for: Social Media and/or Advertising Revocability: I understand that I may revoke this authorization at any time, but such revocation must be in writing and received by the practice via registered mail. Revocation affects disclosure moving forward and is not retroactive. This authorization expires 99 years from date signed. I understand that the practice cannot condition treatment on whether or not I sign this authorization.