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Child's Name *

First Name

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Put location in which you would like therapy to occur (your home, preschool, etc.)

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Please check off all that apply

I am interested in a free screening

It is hard to understand the speech sounds my child makes when he/she talks

I want to learn more about what my child understands/doesn't understand

I am unsure if my child has difficulty verbalizing wants/ideas

My child can have a hard time socializing

My child uses AAC (Alternative/Augmentative Communication Device) to communicate

My child is not yet saying words

I am seeking an evaluation to learn if my child has communication concerns

I am concerned that my child stutters

My child has a difficult time with reading comprehension

Something that is not listed