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F OCUS ON I NDIVIDUAL L EARNING

Client Details Form

Parent's Name [Required]:
EMail [Required]:
Parent 2 Name:

Please indicate the service you are interested in below.
  I am interested in a General Discussion Session
  I am interested in Assessment and Support Program
  I would like to book the Initial Assessment
  I am interested in Auditory Integration Training (A.I.T.) General Discussion
  I would like to book the Auditory Integration Training (A.I.T.) 2 Week Programme
  I am interested in Visual Deficiency Programme General Discussion
  I would like to book the Visual Deficiency Programme Assessment
  I am interested in Neuro-Physiological Movement Programme General Discussion
  I would like to book the Neuro-Physiological Movement Programme Assessment
 
Child's Name:
Child's Date of Birth:
School:
 
Home Tel(s):
Mobile(s):
Address:
 
 
 

For ease of arranging potential programs and follow-up, we would appreciate knowing your current travel plans (if any) and the most suitable time for programme commencement.
If out of Singapore
date returning:
Date interested
in Programme:
Start date of
next school term:
 
Details of concerns:
 
 

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