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Pre-assessment Form

Please complete the form below so we can better understand your child’s needs.

All information is kept private and confidential.

Section 1: Parent / Guardian Information

Section 2: Child's Information

Section 3: Medical Information

Does your child use any of the following? Check all that apply.

Section 4: Additional Notes

During the assessment process, we will require doctor’s notes. If you have them now, please send to info@villagelivingphc.com with the subject line “Doctor’s Notes”

Thanks for submitting! We will contact you within 24 hours.

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