Speech Therapy Screening Registration

Registration Form for Therapy Screenings

Fill out the form carefully for registration
Student Information

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Grade
Parent Information

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Please select your main concern(s) for speech therapy:

Speech: My child does not say sounds correctly and others cannot understand when he/she is speaking. My child replaces a speech sound for another sound (ex. ‘Wabbit’ for ‘Rabbit’)Language: My child does not use language appropriately to communicate and does not understand language. My child has difficulty expressing their wants, needs, and ideas and/or has difficulty following directions.Fluency(stuttering): My child’s speech contains dysfluencies that interfers with their communicationSocial Skills: My child has difficulty initiating conversations, getting along with peers, maintaining conversations, turn-taking, and/or understanding social cues.Literacy/Academic: My child has difficulty with learning letter names/sounds, reading, writing and/or comprehension.
Please select which screening you would like performed:

Speech Therapy- $25
Once you submit this form, one of our staff members will be contact with you to schedule your speech therapy screening.
Should be Empty:

Registration Form for Therapy Screenings