Speech Form

    Speech Form

    Your Name (required)

    Your Email (required)

    My child is between the ages of (required)

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

    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)

    My child has recently been evaluated: (required)

    If yes by whom and when:

    My child currently receives additional services:(required)

    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)