To help me understand the needs of your child please take some time to complete the following information.
use the form below to provide the information you would like me to have
in assessing your child. Simply answer the questions below, fill in the
Verifier box and click Submit. You will then be redirected to
our product catalog to complete secure payment for the first session
using VISA or MASTERCARD. Take as much space as you need to accurately
represent your child and his/ her needs.
addition, in a separate email, please send me a photo or two of your
child, with one being a close up of the face with specific attention to
the eyes. It is OK to email these as an attachment if you are
comfortable with that technology. If you need to mail it, please send it
5647 Bryant Street
Pittsburgh, PA 15206
*Items 1 & 2 must be received before treatment begins.
you are unable to submit the form after answering all of the questions
and filling in the image validation box properly, this may be due to
your computer settings (using an updated version of Mozilla or Internet
Explorer as your web browser may solve this problem).
take the time to answer all of the following questions. Once finished,
please click the Submit button. You will then be redirected to complete
secure payment for the session using VISA or MASTERCARD. Thank you.