Summer Speech Program Registration
Thank you for your interest in the summer speech program through Firefly Speech & Language Therapy LLC!

This program is designed for students who receive speech/language services at school to help prevent regression of skills over the summer months. A copy of your child's IEP will need to be provided prior to the first session. This will allow me to make a therapy plan for your child to continue working on the skills they've learned so far. I do ask that you provide their most recent IEP and/or progress report that includes their speech/language goals. Since we will be using their IEP for goals, these sessions are not eligible for insurance reimbursement. 

Summer sessions will take place in my office: 1920 Turning Leaf Lane SW, Suite #3 in Alexandria (in the Tastefully Simple building). Virtual sessions are available if you are not able to attend in-person. 


Sign in to Google to save your progress. Learn more
Personal Information
Child's Full Name (first and last) *
Child's Age/Grade *
Parent/Guardian Full Name (first and last) *
Address *
Phone Number *
Email *
What is your preferred contact method?
Clear selection
Speech Session Information
*Speech sessions will occur on Tuesday, Wednesday, or Thursday each week. The day and time you choose will be the same across all 4 weeks of the program. 
*Sessions are booked on a first come, first serve basis.
The $300 fee must be paid for upfront. Once scheduled, an invoice will be emailed to you. The invoice must be paid within two weeks to confirm your child's spot. You may pay via cash or check. 
*There are no refunds for a missed day. If a notice is given in advance, one day will be attempted to be made up during the duration of the 4-week program. 

Which session(s) are you interested in? *
Required
How many days per week are you interested in?
Clear selection
Which day(s) are you interested in? *
Required
Please let me know if there are specific times that will work best for you, or if there are specific times that will not work and I'll do my best to accommodate. 
Which service model are you interested in? *
How do you plan to pay? *
You may pay via mail or by dropping your payment off at my office. 
How do you plan to send your child's IEP? *
Would you be interested in continuing services during the school year?
(You are not locked into the response you choose, this just helps me to know who would like more information and how many new families I am able to accept for scheduling purposes.)
Clear selection
Do you have any questions?
Thank you for completing the form. I'll be reaching out to you within 24-48 hours to confirm your registration.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Firefly Speech & Language Therapy. Report Abuse
Google Forms