Speech Screening Registration Form

Speech Screening Registration Form

We're so excited you're interested in registering for our speech screening event! Please fill out the form below. Your registration payment will help provide speech therapy services if needed. We can't wait to see you there! Payment: $30 to confirm screening time. Please Venmo @Study-Hall or a request will be sent to you.
Please note this is not an official evaluation or diagnosis, but an opportunity to determine if a comprehensive evaluation is warranted or services are needed.
Full Name

First NameLast Name
Child's Name

First NameLast Name
Child's Date of Birth

MonthDayYear
Date
Current Grade
School
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Event Date

MonthDayYear
Date
Screening Time
Please describe your child, your speech and language concerns, and why you're interested in a screening.
Please describe your child's interests (favorite food, color, games, sports, activities, etc)
Payment: $30 to confirm screening time.

Until our payment system is updated and active, please Venmo $30 to @Study-Hall
Should be Empty: