Getting to Know You
Answers that help us to better help your child.
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Email *
Client's Name *
Parent/Guardian's Name *
Date of Birth *
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Age *
Phone Number (please use hyphens) *
Mailing Address *
Name of School/Preschool and Grade Level
Did your child receive a speech-language screening by The Speech Path at your child's preschool/school?
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If client is an adult seeking Myofunctional Therapy, what is your occupation
Did someone refer you to The Speech Path for services.  If so, please provide the name of the individual, physician, therapist, school, parent and business associated with the individual if applicable.
We are a private pay therapy center.  We are not in network with any insurance company, including medicaid.  We will provide a monthly statement for your records that contains procedure and diagnostic codes.  It is the client's/parent's/guardian's responsibility to contact the insurance company to determine if out-of-network coverage is provided.  If out of network coverage is provided, it will be the parent's responsibility to submit monthly receipts directly to his/her insurance company in order to seek reimbursement.   *
Required
What therapies are you requesting? Please select all that apply. *
Required
If seeking SUMMER SOCIAL SKILLS GROUPS:  Please select from the following options
Other Summer Offerings:  
Speech-Language Areas of Concern *
Required
Additional Areas of Concern/Therapy Needs
Formal/Medical Diagnosis
Is the client currently receiving Speech-Language Therapy, Occupational Therapy and/or Physical Therapy and if so, where?
Has the client received Speech-Language Therapy, Occupational Therapy and/or Physical Therapy in the past and if so, at what age?
What are your child's interests and favorite activities?
Does your child have a favorite toy they might want to bring to the initial consultation?
Does your child have any specific fears?  If so, please explain.
Does the client have any allergies that we should be aware of? *
What do you consider to currently be the biggest challenges?
What do you love most about your child?
What is your desired vision as a result of being in Speech-Language Therapy and/or Occupational Therapy? *
How would you like to receive therapy services? *
Required
When available, we try to offer preferred days and times for your consultation and ongoing therapy.  What are you preferred days for the initial consult? *
Required
When available, we try to offer preferred days and times for your therapy.  What are your preferred days for ongoing therapy? *
Required
When available, we try to offer preferred times of day for your therapy.  What are your preferred/available time slots? *
Required
Once you submit your form, we will reach out to you to gain more information, answer any questions and schedule your first visit. We can't wait to meet you and your child!  
If you are registering for Social Skills Pairing/Group - we will call you to share details of the program and answer all of your questions!
A copy of your responses will be emailed to the address you provided.
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