When you are ready to get your programme going, complete the following form in as much detail as possible and submit it. You will be contacted shortly to discuss your next steps.

Contact Information
First Name *
Last Name *
Title *
Job Title *
Email *
Email Address 2 *
Street Address 1 *
Street Address 2 *
City *
County *
Postal Code *
Country *
Phone 1 *
Phone 2
Spouse Name *
Childs name *
Childs date of birth *
Biological/ adopted *
Birth order of child *
Does child know they're coming for assessment/ consultation? *
Difference of opinion between parents *
Other professionals opinion *
All adults involved with child *
Details of family relationships *
Marital status *
Details of child affected by crisis/ stress in family? *
Details of pregnancy and delivery *
Details of anything significant in first eighteen months of life *
Details of ability to hear and see *
Details of medical status, neurological, allergies *
Details of sensory, visual, motor issues *
Details of sleep, eating, toileting *
Any other problems and concerns *
Details of educational experiences *
Any formal diagnosis *
Have you attended RDI workshop? *
Yes
No
Details of behavioural interventions *
Details of speech and language *
Details of occupational, physical, music, art, play therapy *
Details of biomedical *
Details of other interventions *