Program: (Required)

Child's Information        
Child's name: (Required)
Age:
Grade 2007 - 2008:
School:
Referred by:

Parent Information         
Parent name: (Required) 
Home Phone: (Required) 
Mobile Phone:
Address: (Required) 
City: (Required) 
State: (Required) 
      
Primary Concerns:

Dr. Rice accepts checks and cash. A deposit of $100.00 sent directly
to the office will confirm your registration.
The balance of your payment is due at the beginning of the program.


  

3802 Ehrlich Rd Suite 310
Tampa, FL 33624
Phone (813) 969-3878
Fax (813) 969-3887
E-mail: info@drwendyrice.com

Copyright . Wendy B. Rice, Psy.D., PA. All rights reserved.