Give
Careers
Capital Campaign
Our Story
History
About Us
Our Team
News
Our Services
AIM Post Graduate Program
K-12 School
Lakemary School Referral
Children Services
Psychiatric Residential Treatment Facility (PRTF)
PRTF Admissions
Case Management
Outpatient Therapy
Adult Services
Residential Living
Day Services
Case Management
Outpatient Therapy
Community Employment
Business Solutions
Transportation
Ways To Help
Capital Campaign
Ursuline Legacy Park
GIVE
Fund a Need
Volunteer
Events
Lakemary Golf Classic
Boots & Bowties
Join The Team
Contact
Our Story
History
About Us
Our Team
News
Our Services
AIM Post Graduate Program
K-12 School
Lakemary School Referral
Children Services
Psychiatric Residential Treatment Facility (PRTF)
PRTF Admissions
Case Management
Outpatient Therapy
Adult Services
Residential Living
Day Services
Case Management
Outpatient Therapy
Community Employment
Business Solutions
Transportation
Ways To Help
Capital Campaign
Ursuline Legacy Park
GIVE
Fund a Need
Volunteer
Events
Lakemary Golf Classic
Boots & Bowties
Join The Team
Contact
My account
Home
>
My account
[woocommerce_my_account]
Close
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
Other
Insurance
Further information
Send
