Please tell us a little bit about your child.
Please Note: Fields labeled with a red asterisk (*) are required.

Basic Information

What is your child's full name? *

What is your child's birthdate? *

What services are you inquiring about?* Physical Therapy (PT)
Speech Therapy
Occupational Therapy (OT)

What type of services ar you seeking? At Home Services
In Clinic Services

What is your reason for referral or concerns? *

If you child has a specific diagnosis, please specify (when/what?)

If your child receives services through other agencies, please specify (which agency/services?)

What kind of funding do you anticipate using?

Contact Information

What is the parent or guardian's name? *

Home phone number: *

Work phone number:

Cell phone number:

Email address: *

Home address:

Feedback

How did you hear about CTC? <!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Strict//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-strict.dtd"> <html xmlns="http://www.w3.org/1999/xhtml"> <head> <meta http-equiv="Content-Type" content="text/html; charset=utf-8" /> <title>CTC Helps Kids - Getting Started with CTC | Children's Therapy Center [www.ctchelpskids.org]</title> <meta name="description" content="" /> <meta name="keywords" content="prosper magazine sacramento" /> <meta name="robots" content="index" /> <meta name="robots" content="follow" /> <meta name="coverage" content="Worldwide" /> <meta name="revisit-after" content="3 days" /> <link href="./images/icons/favicon.ico" rel="shortcut icon" /> <link rel="stylesheet" type="text/css" media="all" href="/skins/default/default.css" /> <link rel="stylesheet" type="text/css" media="all" href="/assets/epoch/epoch.css" /> <link rel="stylesheet" type="text/css" media="all" href="/assets/form_builder/form_builder.css" /> <script type="text/javascript" src="/assets/form_builder/form_builder.js"></script> <script type="text/javascript" src="/assets/epoch/epoch.js"></script> <script type="text/javascript" src="/skins/default/default.js"></script> <script type="text/javascript"> window.onload = function () { bdate_obj = new Epoch('bdate_popup','popup',document.getElementById('bdate'));} </script> </head> <body onload="slideShow.init();"> <div id="wrapper"> <div id="template"> <div id="header"><b>96 West Main St., Ste. B, Woodland, CA 95695 | tel 530.668.1010 | fax 530.668.9799</b></div> <div id="nav"> <div id="nav_btn1" class="nav_rdy"><a href="http://www.ctchelpskids.org" class="nlnk">HOME</a> </div> <div class="nav_spcr"></div> <div id="nav_btn2" class="nav_rdy"><a href="http://www.ctchelpskids.org/about" class="nlnk">ABOUT CTC</a> </div> <div class="nav_spcr"></div> <div id="nav_btn3" class="nav_rdy"><a href="http://www.ctchelpskids.org/faq" class="nlnk">FAQ'S</a> </div> <div class="nav_spcr"></div> <div id="nav_btn4" class="nav_ovr"><a href="http://www.ctchelpskids.org/get_started" class="nlnk">GET STARTED</a> <div class="nav_act"><img src="http://www.ctchelpskids.org/skins/default/imgs/nav_act.jpg" title="" alt="" /></div></div> <div class="nav_spcr"></div> <div id="nav_btn5" class="nav_rdy"><a href="http://www.ctchelpskids.org/jobs" class="nlnk">EMPLOYMENT</a> </div> <div class="nav_spcr"></div> <div id="nav_btn6" class="nav_rdy"><a href="http://www.ctchelpskids.org/employee" class="nlnk">EMPLOYEES</a> </div> <div class="nav_spcr"></div> <div id="nav_btn7" class="nav_rdy"><a href="http://www.ctchelpskids.org/news" class="nlnk">NEWS</a> </div> <div class="clear"></div> </div> <div id="logo_and_banner"> <h1 id="logo"><span style="display:none">Northern California Children's Therapy Center</span><a href="http://www.ctchelpskids.org/"><img src="http://www.ctchelpskids.org/skins/default/imgs/ctc_logo.jpg" title="Northern California Children's Therapy Center" alt="CTC Logo" /></a></h1>  <div id="banner"> <div id="left_arrow"><a href="#PREV"><img src="http://www.ctchelpskids.org/skins/default/imgs/arrow_left.gif" title="PREV" alt="arrow_left.gif" onclick="slideShow.prev()" /></a></div> <div id="right_arrow"><a href="#NEXT"><img src="http://www.ctchelpskids.org/skins/default/imgs/arrow_right.gif" title="NEXT" alt="arrow_right.gif" onclick="slideShow.next()" /></a></div> <div class="clear"></div> </div>  </div> <div class="clear"></div> </div> <div id="center_spcr"></div> <div id="center"> <div id="left"> <div id="left_spcr"></div> <form id="emp_login" action="/index.php/get_started" method="post"> <div id="login"> <a class="btitw">EMPLOYEES</a> <br /><a class="bstitg">resource center</a> <div style="height:10px"> </div> <div class="login_box"> <div class="login_txt"><a class="ltxt">username:</a></div> <div class="login_fld"><input type="text" name="user" class="inptfld_login" onfocus="this.style.backgroundColor='#F8F5E6';" onblur="this.style.backgroundColor='#FFFFFF';" /></div> </div> <div class="login_box"> <div class="login_txt"><a class="ltxt">password:</a></div> <div class="login_fld"><input type="password" name="passwd" class="inptfld_login" onfocus="this.style.backgroundColor='#F8F5E6';" onblur="this.style.backgroundColor='#FFFFFF';" /></div> </div> <div class="login_sbt"> <a href="#" class="frm" onkeydown="document.forms['emp_login'].reset()" onclick="document.forms['emp_login'].reset()"><b>» reset</b></a> <a href="#" class="frm" onkeydown="document.forms['emp_login'].submit()" onclick="document.forms['emp_login'].submit()"><b>» submit</b></a> </div> <div class="clear"></div> </div> </form> <div style="text-align:center; margin-top:5px"> <form action="https://www.paypal.com/cgi-bin/webscr" method="post"> <input type="hidden" name="cmd" value="_donations"> <input type="hidden" name="business" value="christina.michel@ctchelpskids.org"> <input type="hidden" name="item_name" value="Donate to CTC"> <input type="hidden" name="no_shipping" value="0"> <input type="hidden" name="no_note" value="1"> <input type="hidden" name="currency_code" value="USD"> <input type="hidden" name="tax" value="0"> <input type="hidden" name="lc" value="US"> <input type="hidden" name="bn" value="PP-DonationsBF"> <input type="image" src="https://www.paypal.com/en_US/i/btn/btn_donate_LG.gif" border="0" name="submit" alt="Make payments with PayPal - it's fast, free and secure!"> <img alt="" border="0" src="https://www.paypal.com/en_US/i/scr/pixel.gif" width="1" height="1"> </form> </div> <div id="whats_new"> <a class="btitb">WHAT'S NEW</a> <br /><a class="bstitb">latest news</a> <p style="text-align: center;"> <img src="http://www.ctchelpskids.org/skins/default/imgs/wn_icon.jpg" title="" alt="wn_icon.jpg" /> </p>  <div style="height:5px"> </div> <div class="news_box"> <div class="news_date"> <a class="ndtxt"><b>08.04.08</b></a> <br /><img src="http://www.ctchelpskids.org/skins/default/imgs/nws_bult.jpg" title="" alt="nws_bult.jpg" /> </div> <div class="news_info"> <a href="http://www.ctchelpskids.org/news/detail/pid:1267/id:967"><b>CTC Fundraiser Set for September 26th in Sacramento</b></a> <br />CTC is excited to announce plans for our annual fundraiser on Friday,... </div> <div class="clear"></div> </div> <div class="news_box_spcr"> <img src="http://www.ctchelpskids.org/skins/default/imgs/bar_sep_nh.jpg" title="" alt="bar_sep_nh.jpg" /> </div>   <div style="height:5px"> </div> <div class="news_box"> <div class="news_date"> <a class="ndtxt"><b>04.24.08</b></a> <br /><img src="http://www.ctchelpskids.org/skins/default/imgs/nws_bult.jpg" title="" alt="nws_bult.jpg" /> </div> <div class="news_info"> <a href="http://www.ctchelpskids.org/news/detail/pid:1266/id:966"><b>CTC Launches Social Groups</b></a> <br />CTC is launching their long-awaited social groups this Spring. The groups... </div> <div class="clear"></div> </div> <div class="news_box_spcr"> <img src="http://www.ctchelpskids.org/skins/default/imgs/bar_sep_nh.jpg" title="" alt="bar_sep_nh.jpg" /> </div>   <div style="height:5px"> </div> <div class="news_box"> <div class="news_date"> <a class="ndtxt"><b>03.29.08</b></a> <br /><img src="http://www.ctchelpskids.org/skins/default/imgs/nws_bult.jpg" title="" alt="nws_bult.jpg" /> </div> <div class="news_info"> <a href="http://www.ctchelpskids.org/news/detail/pid:1263/id:963"><b>CTC Director Appointed by State Senate to Advisory Commission on Special Education</b></a> <br />On 3/26/08 CTC executive director, Christina Michel-Albers, was appointed by... </div> <div class="clear"></div> </div> <div class="news_box_spcr"> <img src="http://www.ctchelpskids.org/skins/default/imgs/bar_sep_nh.jpg" title="" alt="bar_sep_nh.jpg" /> </div>  <div style="height:5px"></div> <div class="news_box_all"> <a href="http://www.ctchelpskids.org/news"><b>» view all news</b></a> </div> <div class="clear"></div> </div> <div class="clear"></div> <div style="height:20px"></div> </div> <div id="right"> <h1>Getting Started with CTC</h1>