Full name of child in treatment *

First Name

Last Name

Parent or guardian name *

First Name

Last Name

Phone *

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Interests *

Please check boxes below for things your child or family may need or be interested in.

Food needs. Specialized food or medication costs not being met (please explain below)

Toys or games (please name particular items below)

Acquiring a pet, dog, cat, fish or other (please specify below)

Educational equipment or tools (please explain below)

People who will help assist your child with therapeutic connections (please explain below)

Personalized art program interest

Personalized music or drum instruction interest

Personalized healthy food program (please explain needs below)

Outside movement program, Yoga, expressive dance

Summer Program in the gardening with other children learning ways to stay strong.

Communication classes, Healthy ways of expressing feelings through a guided peer program

A place to just hang out and feel safe at Magical Moon Farm

Summer movie afternoons in the barn

Please notify our family of events or programs at Magical Moon Farm