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Request Consultation

To request a consultation please fill out the following form to the best of your ability or email macarena@lovetolearnmd.com directly.

As you await a response back, please check your “spam” folder as sometimes email responses from me will filter there. Thank you!

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Your Name*

First Last

Phone

Email*

Address

Street Address City State / Province / Region ZIP / Postal Code

Child's Name*

First Last

Age*

Diagnosis*

Yes

Please list diagnosis

For which service are you inquiring?*

Other, please describe

Please briefly describe your child's needs

If applicable, please include if your child engages in problem behavior and note degree (mild, moderate, severe) along with a brief description of what behaviors look like.

Is your child vocal?*

Yes

If so, please describe current vocal skills.

What services is your child currently receiving if any?

What day-time hours are you and your child currently available?

LovetoLearnMD, LLC is fully private-pay and does not submit to insurance. Please indicate receipt of this information and if you would like to move forward with inquiring about services and availability.

Yes, I would like to continue inquiring about services and availability.

No, I would not like to move forward inquiring about services and availability.

Maybe, I would like more information.

If over the age of 5, is your child vaccinated against COVID-19?

Yes

If under the age of 5, are caregivers/legal guardians vaccinated against COVID-19?

Yes

How did you hear about LovetoLearnMD, LLC?

Online

Word of mouth

Other

Other, please describe

Name

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LovetoLearnMD, LLC

1204 Adgate Ct Woodbine, Maryland USA, 21797