Intake Form

Pediatric Spaces

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Parent/Guardian First Name*
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Parent/Guardian Last Name*
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Parent/Guardian Email*
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Parent/Guardian Phone Number*
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Child's First Name*
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Child's Last Name*
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Child's Age*
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Would you like to request a virtual or in-person appointment?*
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Do you have any concerns about delays in meeting developmental milestones?*
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Does your child have a specific diagnosis from a medical professional?*
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Does your child have any difficulty with sensory processing or self-regulation?
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Does your child have an IFSP or IEP in place for services through a regional center or school district?
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Does your child have a referral to or services in place through CCS (California Children’s Services)?
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Additional Notes or Comments
Thank you!
We’re so glad you reached out. We’ll review your form and be in touch soon to guide you through the next steps.
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Testimonials

Patients Review

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“We had no idea how much our home setup was affecting our daily life until our consult with My Home Works. After a few simple changes, my husband is more comfortable, and I feel so much more at ease knowing we’re prepared for the future.”

Maggie T.
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Age in Place
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“I was dealing with back pain from working at my kitchen table all day. The virtual consultation was so easy, and the follow-up plan was detailed and practical. I genuinely feel better working now.”

Jason L.
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Home Office
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“The suggestions we got for our son’s sensory space have made a huge difference. It’s easier for him to regulate and easier for us to support him at home.”

Naomi K.
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Pediatric Sensory
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“I didn’t qualify for traditional home health support, but My Home Works filled that gap perfectly. I felt heard, supported, and empowered to make meaningful changes in my space.”

Elena V.
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Post-Recovery
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“What I appreciated most was how non-intimidating the whole process felt. No sales pitch—just thoughtful, professional help that truly made our home feel safer.”

Thomas M.
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Family Caregiver
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“I didn’t realize how many small things in my home were slowing me down. The consult helped me see my space in a new light, and the recommendations were so doable—even on a budget.”

Paul D.
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Age in Place
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“We were overwhelmed trying to find the right setup for our daughter’s play space. My Home Works gave us simple, expert guidance that made everything feel more manageable—and more joyful.”

Rachel & Tim S.
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Pediatric Spaces
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