Peak Potential Therapy Homepage
HOLLY REIMANN, MA CCC-SLP
Peak Potential Therapy

Therapy Treatments & Resources for Families with Children
Affected by Autism & Related Disabilities in Cleveland / Akron Ohio.

10 Great Reasons to Choose Peak Potential Therapy
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 call: 330.405.8776

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REGISTRATION FORM


Client & Family Information

Thank you for your interest in Peak Potential Therapy. To receive further information and our enrollment package, please complete the following registration form. Confirm your request by clicking SUBMIT below. Someone will contact you by phone to answer all of your questions. In addition, an enrollment package will be sent to the address you provide below within one week of your submission.

Child Information
First Name* Last Name*
Birth Date* (m/d/y)
Diagnosis
Services Requested*
Additional Information
How did you hear about us?* Please specify:
Best Time to Contact
Time of day* Best phone number*
Parents & Guardian Information
Mother First Name Last Name
Father First Name Last Name
Guardian First Name Last Name
Contact Information
Main Contact:
Phone Home*
Phone Cell
Phone Work
Address 1*
Address 2
City* / State*
,
Zip* / County
,
Email*

We respect your privacy. Under no circumstances will we use your personal information for any purpose other intended.
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