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Refer a Child
Recipient Screening Questionnaire
Do you know of a child who can benefit from having a Safe Sensory Room "autism haven" in their home?
Please fill out this screening form and someone from our staff will be in touch with you!
Guardian/Caregiver's First name
Guardian/Caregiver's Last name
Email
Phone
Child's Name
Child's Age
Child's Gender
Male
Female
City
State
Postal / Zip code
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