ACT Program Intake

Please have the primary caregiver complete the fields below. The information requested will be used to better serve your family.
  • Date Format: MM slash DD slash YYYY
  • Click the plus sign to add additional names
    Child Name (First & Last)Date of BirthSchoolGradeTeacher 
  • Please check any of the following areas in which you have concerns for your child, yourself and/or family, and are interested in accessing more support: