Discovery Call LocationScottsdaleTucsonChild's InformationHiddenClient's Full NameCarlos NovotnyClient's Full Name First Last GenderMaleFemaleOtherDate of Birth MM slash DD slash YYYY Age GradePre-KKindergarten1st2nd3rd4th5th6th7th8th9th10th11th12thSchool Teacher's Name Teacher's Email Other (Additional Information)Personality / InterestsEmergency InformationMedical Allergies Food Allergies Other Additional InformationCurrent IEPYesNoCurrent IEPOTPTSPVT504 PlanHold down “Command” to select multiple Private TherapyYesNoPrivate Therapy TypeOTPTSPVTCounselingPlay TherapyHold down “Command” to select multipleTherapy NotesDiagnoses None ADHD Amblyopia Anxiety Apraxia Astigmatism Auditory Processing Disorder Autism Convergence Insufficiency Depression Developmental Delay Dyslexia Dysgraphia Dyscalculia Executive Functioning Challenges Gifted Hypermobility Obsessive Compulsive Disorder Oculomotor Dysfunction Oppositional Defiance Disorder Sensory Processing Disorder Speech Delay Twice Exceptional Diagnoses DetailLast Vision Exam/DR Parent InformationParent First Parent Last Email Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCellAppointment InformationDate of Discovery Call MM slash DD slash YYYY Evaluation Date MM slash DD slash YYYY Evaluation Time Hours : Minutes AM PM AM/PM Eval Type Comprehensive Primitive Reflex Virtual Comprehensive HiddenEval Summary0 – Form Submitted1 – Call Scheduled2A – Call Complete (Evaluation Scheduled)2B – Call Complete (No Fit)2C – Call Complete (Did Not Schedule)3 – Evaluation Scheduled4A – Evaluation Complete4B – Zoom Call Complete Ready To Schedule5A – Scheduled5B – Waitlisted5C – LostReferral Source Attended Megan's PresentationCONTACT FORMCurrent/Former S2S ClientESA ReferralEye DoctorFacebookFlyerFriendHow did you hear about us?Internet SearchNeuropsychologistOccupational TherapistOtherPediatricianPencil Grip AssessmentPhysicianPsychologistReturning S2S ClientSchoolSpeech TherapistTeacherReferral Source – Detail Please be descriptive as possible so that we can thank referrers. Zoom Call To Be Determined Yes Zoom Date MM slash DD slash YYYY Zoom Time Hours : Minutes AM PM AM/PM Sales Notes Deposit $ Send Scribble 2 Script Evaluation Confirmation Yes In order to automatically send this email, you must have an evaluation date and time entered above.Send Signs and Symptoms Checklist Yes Send "Thank You For Speaking With Me" Email Yes HiddenS/S Checklist Emailed Current Client Status(Required)Discovery Call Complete-Evaluation ScheduledDiscovery Call-Completed – Not a FitDiscovery Call Completed – Evaluaton DeclinedEvaluation Scheduled Online Δ
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