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Intake Packet (English & Spanish)

  • Please download Notice of Privacy/HIPAA for your records:
Notice of Privacy/HIPAA

Fill Out Intake Packet Online:

We are an interdisciplinary clinic.
We strive to apply a holistic approach to child development, and care.

Somos una clínica interdisciplinaria.
Nos esforzamos por aplicar un enfoque holístico al desarrollo y cuidado infantil.

All 9 sections must thoroughly be completed. This will provide the best care and treatment 
for your child. We appreciate your time and attention to detail.

Las 9 secciones deben completarse completamente. Esto proporcionará la mejor atención y 
tratamiento para su hijo. Agradecemos su tiempo y atención al detalle.

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I Have Concerns

"Where do I go, what do I do?"

My child frequently struggles with: bright lights, loud noises (vacuum), mouth on non-food, difficulties with movement, runs into things, trips easily, motion sickness, easily upset, avoids touch or textures

Is your child a super picky eater, does not eat a variety of hard / soft foods, or struggles chewing food (spits food out, over stuffs, chokes easily)?

If your child is having difficulty, or not meeting their age level milestone, you may want to consider a Developmental Screening or speak with your pediatrician.

Developmental Age Level Check: Social Emotional, Language (Communication), Thinking (Cognition), Movement (Physical Development)

Developmental Milestones
on the CDC Checklist

Concerns for
Autism

Pool Protocol

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English
Spanish

Program Release Forms

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English
Spanish

HIPPA and Shorkey Policies

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English
Spanish

Volunteer for Shorkey

Lend your time to children in need. To get started, just fill out the form below. A member of our team will then contact you to discuss your request.