Speech Language & Hearing Clinic Scheduling Form

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Speech Language & Hearing Clinic Scheduling Form - Fall 2020

September 7 - December 3, 2020

230 Memorial Hall, 1 University Circle, Macomb, IL 61455
Contact us at (309) 298-1955
Email: SPA@wiu.edu

Thank you for your interest in attending the WIU Speech-Language & Hearing Clinic!
We are honored to be able to serve you and your loved ones at no cost.

Client Information

Client's Name *

Date of Birth: (Month/Date/YYY) *

Age *

Sex (Gender) *

Male

Female

Caregiver(s) Name(s) *

Phone Number:

Preferred time to be contacted:

Availability

Our clinic is open Monday-Thursday from 8:00-5:00.

Each client is assigned to either Monday/Wednesday OR Tuesday/Thursday for 50-minute sessions.

Please indicate your scheduling preferences by circling your available times from the choices below.

PediatricTimes (birth-18yrs)

8:00

9:00

10:00

11:00

12:00

1:00

2:00

3:00

4:00

MON/WED

TUE/THU

Adult Times (18yrs & older)

8:00

9:00

10:00

11:00

12:00

1:00

2:00

3:00

4:00

MON/WED (Note: 1pm time is not available)

TUE/THU (Note: 3pm time is not available)

Service Delivery Options

Our clinic is proud to differentiate services in order to best serve our clients. Both individual & group therapy options are available.

Research has proven that group therapy, such as Speech Sound Groups (Articulation & Phonology), can be just as, and in some cases more, beneficial for our clients than individual therapy alone.

Group therapy facilitates the generalization of newly developed communication skills and allows for increased peer interaction and peer support.

Please feel free to discuss these options with your student clinician and supervisor.
Understand that when you consent to group therapy, other families may be observing that session with you.

See back for all group therapy options.

I am interested in (circle one): *

Individual Therapy

Group Therapy

No Preference

Please select any preferred Group Intervention options:

Toddler Talk (Age 18-36 months): Therapy will primarily focus on improving verbal communication, social skills, and language comprehension.

Little Learners (Age 3-6 years): Therapy will primarily focus on early literacy, peer interactions, social skills, and verbal communication.

School-Age Smarties (Age 6-9 years): Therapy will primarily focus on direction following, literacy, peer interactions, language complexity, and verbal reasoning.

L is for Literacy (Age 7-10 years): Therapy will primarily focus on reading comprehension, writing/spelling, grammar, narratives, and editing.

Adolescent Group (Age 10-14 years): Therapy will primarily focus on peer interactions, higher level language skills, literacy strategies, problem solving/reasoning, and direction following.

Speech Sound Group (Articulation & Phonology): Speech sound production goals will be individualized for each child. Therapy will primarily focus on the production of target speech sounds and generalizing the production of speech sounds during peer interactions.

Please submit this form online. Thank you!

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