|
Therapeutic Service
Desired: Date
of Request________________
__ Individual therapy sessions
__ Group therapy sessions (3-10
persons)
Specific Disability and Help
Requested:
_______________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Time-frame Desired for
Services: (Sessions are 45-60 minutes)
Preferred Start Date
____________________________________________________________________________
Preferred Frequency of Sessions
___________________________________________________________________
Preferred Days & Times for Ongoing Sessions
_________________________________________________________
Other Information
Needed:
Contact Person
_____________________________________________________________________________________
Agency (if applicable)
________________________________________________________________________________
Contact Address
____________________________________________________________________________________
__________________________________________________________________________________________________
Contact Phone & Email Address
________________________________________________________________________
Please save this form as a document, and email
it to mckenje@special-access-services.com,
or print out and mail to Ken McCormick, Director of Operations, at
Special Access Services, 3401 Spanish Trail, #349, Delray Beach,
FL 33483-4780. | 
