Functional Kids Therapy Center LLC
OUTPATIENT PEDIATRIC INTAKE FORM

Child's Information

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Parent's Information

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BATTLE CREEK LOCATION

777 Goguac St W. Suite B2
Battle Creek, MI. 49015

Phone: ( 2 6 9 )  2 2 3 - 7 7 8 6
Fax: ( 2 6 9 )  9 6 2 - 9 5 6 9

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CALEDONIA
 LOCATION

9809 Cherry Valley SE Suite D
Caledonia, MI. 49315

Phone: ( 6 1 6 ) 5 3 6 - 2 2 1 1 
 Fax: ( 2 6 9 )  9 6 2 - 9 5 6 9

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LOCATION
COMING SOON

403 North Grand Street
Schoolcraft, MI. 49087

Phone: ( 2 6 9 ) 3 0 0 - 7 3 93 
 Fax: ( 2 6 9 )  2 2 5 - 0 1 0 5

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