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Application Form

3990 Westerly Place # 180
Newport Beach, CA 92660
Phone: (949) 375-7075
Email: [email protected]

Name *

Email *

Phone

Gender *

Birthday

Mother's Name

Occupation

Father's Name

Occupation

Address *

How severe are the challenges and how are they affecting this individual's daily life?

What is the main reason you are interested joining Brain Reconnection?

Have you tried any other therapies ? If yes, have you seen any positive changes?

Please check the box next to each developmental issue that the client has experienced/ or is currently experiencing:

Autism Spectrum Disorder ADD or ADHD Auditory Processing Disorder Language Disorder Cerebral Palsy Vision Impairment Traumatic Brain Injury (TBI) Down Syndrome Eating/Feeding Disorder Epilepsy and Seizure Disorders Fine Motor Delay Gross Motor Delay This individual does not have any official diagnosis at this time.

How did you hear about us?

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3990 Westerly Place # 180 | Newport Beach, CA 92660

Phone: (949) 375-7075 | Email: [email protected]