Client Intake Form

Client Intake Form

Service Requested (as of July 1, 2022)*
MM slash DD slash YYYY
  • Full payment or a purchase order is required at the time of the appointment.
  • Evaluation reports will be completed 4-6 weeks from the time of testing.
  • Insurance is not accepted.
Name*
Home Address*
Child's Name*
Does the child have an IEP (current or prior)? If yes, please email all reports to jneal@robinowitzcenter.org*
Has the child ever been tested before? If yes, please email all reports to jneal@robinowitzcenter.org.*