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Request a Job Interview
 
Select the position you wish to apply for:



Name(s):

Last name(s):

Current/Previous employer:

E-mail address: 

Phone number:

Address:

Date of birth: 

Title/Credentials: 


Describe your experience in the care of persons with developmental disabilities: 

max:1000 char.
























































 


Request Services or Initial Consultation
 
Where would you like to receive services?


Requested Services/Servicios Solicitados:
speech therapy/terapia de lenguaje
occupational therapy/terapia ocupacional
habilitation/habilitación
respite/respiro
Educational Therapy/Programa Académico
Behavioral Consultation/Consulta Conductual


Why are you requesting these services?
max:1000 char.


Name(s):

Last Name(s):

Date of Birth:

Parents or Legal Guardians:

Diagnosis:

E-mail address:

Phone number:

Address:

School:

Referred by:

What are your primary concerns?
max:1000 char.


How does the person communicate?


Types of games/play that he or she enjoys:
plays with hands or body (self)
jumping and spinning
repetitive or ritualistic play
manipulate objects or explores with mouth
ball play
figurine play
simbolic/representative play
imaginary play


Behaviors you would like to discuss with a specialist:
aggression
self-aggression
self-stimulatory behaviors
obsession with specific objects or themes
avoids social situations
excessive crying/tantrumming
mouths or bites objects or him/herself
other

¿What does he or she most enjoy?

¿What causes the most distress?

¿How was early development/life/pregnancy?
max:1000 char.

¿How you describe the development of his or her communication skills over time?
max:1000 char.

¿How does he or she behave around same age peers?
max:1000 char.

Schedule in which you would like to receive services:
max:1000 char.

 


I want to help!
 
What would you like to donate?


Name(s):

Last name(s):

Institution:

Title: 


E-mail address: 

Phone number:

Address:

 
Comments:

max:1000 char.

















































 
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