Teaching Clinic Sign-up
Summer 2023
Child Name:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Parent or Guardian:
*
First Name
Last Name
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
Please enter a valid phone number.
Email:
*
example@example.com
Briefly describe your concerns or reason for seeking speech & language therapy:
*
Schedule, Preferences, Fee
Our summer program will run from June 13 to August 16 8-9 spots will be available this summer The Clinic fee will be $45 per session and full payment is due on the first day. The Clinic does not participate in third party payments such as medical insurance plans, Medicare, or Medicaid providers. No refunds will be made if the client withdraws from services without consultation and approval of the Clinic Director. Independent private services are also available through the Clinic and are provided by certified speech-language pathologists. For further information on these services, please contact the Clinic Director.
What times is your child available for therapy?
*
Between 10:30am-12:30pm
Between 1:30pm - 4:30pm
Therapy will be provided on Tues/Wed or Tues/Thurs. Which days do you prefer?
*
Tuesday & Wednesday
Tuesday & Thursday
Are you interested in 1:1 or group therapy?
*
1:1
Group
1:1 and Group
Submit
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