Speech Glam Screening Form

1

Child's Name* This field is required.

2

Child's Birthday* This field is required.

3

Child's Gender* This field is required.

Female

Male

4

CHILD'S DAYCARE/SCHOOL* This field is required.

TYPE NA IF CHILD IS NOT IN DAYCARE/SCHOOL

5

Parent's Name* This field is required.

First Name

Last Name

6

Parent's Email* This field is required.

example@example.com

7

Phone Number* This field is required.

876-555-5555

9

Insurance Card Upload

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

10

Do you currently have a referral for a speech evaluation from your child’s pediatrician?* This field is required.

Yes, I have it and can upload it now

No, please request it from the doctor

11

Upload Speech Referral

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

12

Please provide your child's pediatrician information and the office will request referral for you

13

Has your child been evaluated by a speech-language pathologist in the last 6 months?* This field is required.

YESNO

14

If yes, please provide when and where your child was evaluated.

15

Has your child been diagnosed with any of the following? (Select all that apply)* This field is required.

Autism (ASD)

Hearing Concerns

Behavioral Concerns

Speech Sounds Concerns

Feeding/Swallowing Concerns

Developmental Delay

16

What are your concerns?* This field is required.

Not talking enough

No using any words

Not following directions

Speech Sound Errors

Stuttering

Limited Vocabulary

17

By submitting this screening form, I understand:

This form does not schedule an appointment.

Speech Glam will review my information and contact me with next steps within 24–48 hours.

Additional insurance or referral information may be required before scheduling.

18

SignatureI understand and agree

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