Parent/Caregiver Name *

First Name

Last Name

Phone *

(###)

###

####

SMS Privacy Policy *

As a current or prospective customer you understand that you can text us STOP at any time to opt out of receiving SMS text messages from us. Your mobile information will not be shared with any third parties/affiliates for marketing/promotional purposes. All policies are followed as per CTIA guidelines 5.2.1. At any time if you want your information to be removed, you can contact us via our email address or regular mail. By leaving my phone number, I agree to receive text communication from you. This includes automated appointment reminders and other important communication with my child's speech-language therapist.

I agree

I do not agree

Child's Date of Birth *

MM

DD

YYYY

What services are you interested in? *

Initial Consultation

Speech Sound Evaluation

Speech Sound and Language Evaluation

Review of Current Evaluation

Speech-Language Service (In-person)

Speech-Language Service (Teletherapy)

IEP Consultation or Attendance

Professional Consultation