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Free School Tour Form Request

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What school is your child attending?

What scholarship does your child currently have?

* Are you happy with the progress your child is making at school?

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Is Your Child Receiving Therapy?

Select YES or NO in any of the Therapies listed below

Aba Therapy

Yes

No

Speech Therapy

Yes

No

Physical Therapy

Yes

No

Occupational Therapy

Yes

No

What insurance does your child have?

Medicaid

Other-please list below

Other Insurances please list below

Would you like to set up a tour of our school?

Yes

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What is the best time to contact you?

8-4 PM

4-9 PM

Is your child current enrolled in a summer camp?

Yes

No

Would you like more information about our camps and therapy?

Yes

No

CARRIE BRAZER CENTER FOR AUTISM MIAMI FL