Child's Birthday*

1. What habit are you seeking support for?*

2. How long has this habit been present? *

3. Has your child expressed a desire or willingness to stop this habit? *

4. Have you attempted habit elimination in the past? *

5. Are you able to support daily expectations at home during a short-term program? *

7. I understand this is a private pay program and requires a 60 minute evaluation prior to enrollment. *