Initial Contact about Speech Therapy Services
If you believe your child would benefit from ST services and would like someone to follow up with you about an evaluation, please complete and submit the following confidential form. Someone from our team will be in touch with you shortly. We look forward to working with you and your child!
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Email *
Child's Name *
Date of Birth: *
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DD
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Address *
Insurance Provider: *
Pediatrician/Family Doctor: *
Diagnosis/Area(s) of Concern:
Has your child had an OT evaluation in the last year? (If yes, please submit to our office manager at info@carolinatherapysc.com) *
Parent Contact
Parent(s)/Legal Guardian Name: *
Best contact phone: *
Best contact email: *
*
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