Submit your form

Special Needs Support Registration

First name

Last name

Contact Phone Number

Age in years

If you are a parent/carer applying for a child under 16 years old, we kindly request that you provide your full name

Briefly describe the medical history, including any diagnosed conditions, developmental delays, speech disabilities, ADHD, autism spectrum disorder, or other neurodivergent disorders.

Upon receiving your submission, our team will review your application. We will then contact you via phone to discuss your application further and determine if you qualify for the program. Please note that this form is not the final step, but an initial application to begin the process. We appreciate your understanding, and we look forward to speaking with you soon

Yes, I understand and happy to be contacted via phone

Confidentiality is of utmost importance to us. Rest assured that all the information provided in the enrollment form will be treated with strict confidentiality.

Yes, I understand

FAITH HOMOEOPATHY

Online/Maidenhead Clinic

Submit your form

Special Needs Support Registration

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