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HOME PHONE: (if different from applicant)

HOME PHONE: (if different from applicant) 2025

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The document is a service request form for Therapeutic Learning Consultants, designed to collect information about a child seeking therapeutic services. It includes sections for child and guardian details, diagnosis, treatment history, current services, problem behaviors, communication skills, desired services, and funding information. The form also outlines the process for scheduling a consultation and provides contact details for submission.

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