Speech Form

Speech Form

Your Name (required)

Your Email (required)

My child is between the ages of (required)
0-33-56-88+

My child has a relevant medical/educational diagnosis: (required)
YesNo

If yes please list:

I am able to understand my child at least: (required)
Less than 25% of the timeBetween 25-50% of the time50-75% of the time75%-99% of the timeI always understand my child

The following individuals have expressed concerns over my child’s fine motor/sensory skills: (required)
DoctorTeacherMyselfFamily member (grandparents, aunts, uncles, etc.)Other

Please list a few errors your child is presenting with:(required)

My child hearing has been screened:(required)
YesNo

My child has recently been evaluated: (required)
YesNo

If yes by whom and when:

My child currently receives additional services:(required)
YesNo

If yes please provide list of current services:

My level of concerns regarding my child’s fine motor and/or sensory development is: (required)
Minimal, I am not overly concernedMarginal, I am somewhat concernedUrgent, I am very concerned

Please list the best dates/times for us to call: (required)