Infinity Neurodevelopment Center Information Form

General Information Request

First Name *

Last Name *

Phone *

Email *

Your Child's Full Name *

Patient's DOB *

Why are you seeking our services? *

Has your child received a diagnosis? If, yes, please share it. *

What therapies or interventions have you tried? *

What are you hoping to improve or see change in your child? *

Are you interested in an intensive therapy program (1-4 weeks, 2-4 hours per day) *

Yes

Not sure yet, I’d like more information

Which Infinity office are you closest to or most interested in? *

I Consent to Receive SMS Notifications, Alerts & Occasional Educational Communication from Infinity.