Spell to Communicate Rx Interest Form

Intake form for Spell to Communicate Rx Lessons
Are you looking for a way to help your non-speaking or unreliable speaking child, teen, or adult communicate more effectively?

📍 All sessions will take place in person at:
2607 Crane Rd, Waxhaw, NC 28173

🧠 What is Spelling to Communicate (S2C)?
S2C is a motor-based communication method that supports individuals with apraxia and other complex communication needs to express themselves by spelling on a letterboard. It builds communication, literacy, and independence while presuming competence and honoring the intelligence of every learner.

👉 Learn more from I-ASC:
🔗 https://i-asc.org (https://i-asc.org/)

👋 Who am I?
I’m Dr. Denise Simonelli—an educator, dyslexia specialist, and now an S2C Practitioner in Training. I’m passionate about empowering neurodivergent learners through motor-accessible, literacy-rich, and trauma-informed instruction.

📍In 2026, I’ll be launching Spell to Communicate Rx at The Reserve, a nonprofit retreat-style learning center located on my 2.3-acre property in Waxhaw, NC. It will serve families through 1:1 S2C, nature-based regulation, parent coaching, and small-group education.

This is just the beginning—and I’d be honored to walk alongside your family on this journey. 💬✨
Student Information
Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Email Address
Phone Number
Please enter a valid phone number.
Grade
Parent Information
Parent/Guardian 1

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Parent/Guardian 2

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Student Residence Information
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Parent/Guardian 1 Residence Information (if different from above)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian 2 Residence Information (if different from above)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact 1
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Emergency Contact 2
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Physician and Medical Information
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Preferred Hospital
Insurance/Health Coverage (Company)
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns.

Previous School
School Name
City
State
Date Started

MonthDayYear
Date Ended

MonthDayYear
Current Education Setting (home, school, hybrid, therapy program)
Please explain Current Education Setting
Who referred you or how did you hear about S2C?
Has your child had any previous communication therapy? (Speech, AAC, RPM, S2C, OT, PT)
What is your childs favorite activities or interests?
How does your child usually express wants, needs, feelings? (gestures, vocalizations, devices, etc)
COMMUNICATION & REGULATION
Does your child use words, sounds, or vocal approximations consistently?
How does you child show when they are frustrated, excited, or overwhelmed?
What helps your child self-regulate when upset or overstimulated (deep pressure, movement, quiet time, music)
Are there specific triggers or stressors that tend to cause dysregulation?
Are there any sensory preferences or sensitivities? (sounds, light, touch, movement, textures)
Are there any subjects or topics that motivate or engage your child most?
Medical & Developmental Overview
What are your child's diagnosis or conditions? (Autism, Apraxia, ADHD, Down Syndrome, Genetic Disorders)
Should be Empty:

Intake form for Spell to Communicate Rx Lessons

Student Information

Parent Information

Student Residence Information

Parent/Guardian 1 Residence Information (if different from above)

Parent/Guardian 2 Residence Information (if different from above)

Emergency Contact 1

Emergency Contact 2

Physician and Medical Information

Previous School

Current Education Setting (home, school, hybrid, therapy program)

COMMUNICATION & REGULATION

Medical & Developmental Overview