Ready to begin therapy? New Client Form Below Scroll down if you just want to chat. Ready for Speech Therapy?New Client Form: When you are ready to enroll in speech therapy please fill out the following information: *Parent’s Name *Child’s First and Last Name *Child’s DOB *Phone Number *Email Address *Preferred form of communication PhoneText (fees may apply, check with your service provider)Email *Primary Insured’s Name *Street Address *City, State, Zip *Insurance Company *Scheduling Preferences MondayTuesdayWednesdayThursdayFriday Optional Message: *Does your child have any allergies? YesNo If yes, please describe: Dismissal Form: If your child will be picked up from therapy by someone other than you, please provide the name and contact for anyone your child may be dismissed to: *Are you a human? UNCHECK this box if you are not a robot. *Parent's Name *Child's First and Last Name *Child's DOB *Phone Number *Email Address *Preferred form of communication? *Preferred form of communication? Phone Text (fees may apply, check with your service provider) Email *Primary Insured’s Name *Street Address *City, State, Zip *Insurance Company *Scheduling Preferences *Scheduling Preferences Monday Tuesday Wednesday Thursday Friday Optional Message *Does your child have any allergies? *Does your child have any allergies? Yes No Allergies: If yes, please indicate here if your child has any allergies. If yes, please describe. Dismissal Form: If your child will be picked up from therapy by someone other than you, please provide the name and contact for anyone your child may be dismissed to: 1 + 7 = Submit JUST WANT TO CHAT? *Parent's Name Child's First Name Child's Age *Phone Number *Email Address Preferred Form of Communication? Preferred Form of Communication? Text Email Phone Message 2 + 6 = Submit
