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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REGISTRATION FORM



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.


Child Information
First Name* Last Name*
Birth Date* (m/d/y)
Diagnosis
Service
Service Requested* Other, please specify:
How soon are you looking to start services*
Best Time to Contact
Time of day* Best phone number*
Additional Information
How did you hear about us?* Please specify:
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*

 Thank you for your time in completing this registration form!

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