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Specialized Services
Case Management
Outpatient Therapy
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Outpatient Therapy
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PRTF Contact Form
*Please allow 1 week for a response.
Name
Relationship to Child
Email
Phone
Message
Student Information
Age
Sex
IEP Designation
IQ and Academic Level
Does the child have a formal diagnosis of an intellectual or developmental disability?
Please list diagnosis:
Please explain any medical conditions:
Please explain other mental health issues
State Student Resides In
Current Placement
Anticipated Funding Source
Private Pay
School/IDEA funded
Children & Family Services Organization
Dept. of Disabilities/Regional Center
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