Thank you for your interest! Please complete the form below. All submissions will be reviewed based on eligibility criteria.

Legal first name

Last Name

Phone *

Email *

Preferred Method of Contact *

Phone

Email

Are you a: *

Parent/Guardian

Educator

Service Provider

Please tell us why you would like to Meet with Dr. Eko (Check all that apply) *

Learn more about medical evaluation for Autism/ADHD

Learn more about holistic solution for Autism/ADHD

Connect with other parents/families

Are you seeking services for a child with: *

ADHD

Autism

Both

Although we don't accept insurance, we offer multiple payment plans, FSA/HSA. Are you willing to pay out-of pocket for the services we offer? *

Yes

No

Is your child in therapy? *

Yes

No

Availability for the Meet and Greet (Choose all that apply): *

Weekday Morning

Weekday Afternoon

Which state you're located in? *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.