YOUR First & Last Name *

Phone Number *

What is your CHILD's first name? *

What is your CHILD's date of birth? *

Is your child male or female?

What are your main concern(s) with your child's speech and language skills? Such as pronunciation (articulation); stuttering (fluency); lack of words or sentences (early language); vocabulary or grammar (language); autism; dyslexia; etc *

Has your child received a Speech and Language Evaluation or Speech Therapy in the past? *

If Yes...

Has your child been diagnosed with any potentially relevant medical conditions, such as autism, dyslexia, cerebral palsy, recurring ear infections, hearing impairment, etc? *

If Yes...

What language(s) are spoken in your home? *

What percentage of your child's spoken words do YOU understand? *

What percentage of your child's spoken words would a LESS FAMILIAR adult understand (e.g. A friend or family member who only sees your child occasionally)? *

Do you have concerns with how your child is understanding what you say (ex: following directions, answering questions, understanding stories being told, etc.)? *

If Yes...

Do you have any concerns with your child's hearing abilities? Consider how he/she reacts to sounds or words (i.e. doorbell, phone, calling his/her name). *

If Yes...

Has your child had a hearing screening? *

Does your child get frustrated when he/she is not understood? *

Does your child look at you (make eye contact) and react to your expressions (laugh, smile, etc.) as you would expect? *

If No...

Did (or does) your child have any difficulty with feeding (i.e. gagging, difficulty swallowing, frequent coughing during meals)? *

What days and times work best for you and your child to attend a weekly 30-minute live therapy session using Zoom? *

Do you have a computer or laptop with a webcam, or an iPad (or other large tablet) for live therapy calls over Zoom? *

Currently, I am an out-of-network provider. I am in the process of accepting some insurance plans. Please provide your insurance carrier for reference:

Use this box to provide any additional information about your concerns that is not covered in the questions above (optional).