Contact – Blooming Potential

318-582-5889
[email protected]

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About us
Services
Team
Blog
Contact

Are you ready to start your child’s therapy journey together?

Provide your contact details below and someone from our team will be in touch with you soon. We’re so excited to meet you and your child and to help them reach their full potential!

First and last name (Person completing form)

Cell Phone Number

Home Address

Your child's first and last name

Your child's birthdate

Your child's pediatrician

What insurance company does your child have?

Please indicate any diagnoses that your child currently has:

ADHD. Autism Spectrum Disorder. Sensory Processing Disorder. Speech/Language Delay or Disorder. My child does not have a diagnosis.

Please indicate areas of concern:

Falls a lot. Easily angry. Speaking clearly. Feeding concerns. Limited to no speech. Social and Play concerns. Delayed in skills that you think they should demonstrate by now. Seems to not understand you/not able to follow age appropriate directions. Difficulty with any of the following: crowds, sounds, lights, tastes/textures, touch. Behaviors (more tantrums than typical for age, hitting, biting kicking, slapping, damaging property, hurting self). Participates in dangerous activities without realizing the danger/potential for harm (will run in the road, climb really high without fear of falling, etc).

What service(s) do you feel would be helpful for your child?

Speech Therapy. Occupational Therapy. Applied Behavior Analysis.

Can you share any and all details that you feel it's important for us to know in order to help your child the most?