myPad Program

myPad Program Application

Once your application is submitted you will be contacted by our staff to schedule a verbal intake consultation to finalized needs and waiting list time frame.

First Name: *
Last Name: *
Childs Name: *
Diagnosis: *
Address Street 1:
Address Street 2:
City:
Zip Code: (5 digits)
State:
Daytime Phone: *
Evening Phone: *
Email: *
IEP Goals: *
Hobbies and Interests: *
Comments: