Application

Today's Date *

Full Name *

Email *

Phone *

State or country *

What is your handle for your preferred social media messaging platform(s) (i.e., telegram, signal, messenger, IG) *

What Are Your Child's Main Challenges? *

If you had a magic wand, what would be the one thing you would want to improve? *

What do you hope to gain from this program? *

On a scale of 1-10, how committed are you to achieving those results? *

Would all other caregiers in the home be completely on board with the action steps necessary to get results and not undermine your decisions? *

Yes

Not sure, but crossing my fingers

I understand that this program is for those who are committed to taking action and making the necessary changes to help my child overcome his/her learning and/or behavior challenges.

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