INTAKE
FORM

Help me get to know your child.

Thank you for taking the time to fill out this form so that I can tailor an approach customized for your family/child.

Child's Name

First Name

Last Name

Child's Age/Grade

Parent/Guardian's Name

First Name

Last Name

Email

Phone Number

Town

How did you hear about Wendy?

How can I help?

(* required)

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Reading gives us a place to go when we have to stay where we are.

-Mason Cooley

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