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Order Request- Counseling Session Nicole's Speech & Language Consultations, LLC
After you fill out this order request, we will send you an invoice for $30 to your email address before your counseling session begins. This service is for emotional support only. Your session will be private and confidential. Each session is 30 minutes long. Please do not share any private or personal medical information regarding you or your child. We would appreciate you leaving a customer review on Facebook as well.
https://www.facebook.com/NicoleSLP4U/reviews
(For office use only: ORDER REQUEST #________________________________________________________________)
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Email
*
Your email
Which method of contact for your session do you prefer?
By Zoom meeting (camera on)
By Zoom meeting (camera off)
Phone Call Only (Contact Number: 631-306-4203)
Text Messaging Only
Clear selection
Are you a new or existing customer?
I am a new customer
I am an existing customer
Clear selection
What category of speech or language impairment do you or your child have?
*
Toddler/Child Speech Disorders
Adult Speech/Language Disorders
Child Language Disorder/Delay
Early Childhood Development
Speech Sound Disorders
Stuttering and Fluency
Autism Spectrum Disorder
Reading Readiness
Accent Modification
Speech Delay
Lisp
Apraxia
Social Skills
Voice Disorders
None
Other:
Required
What type of a counseling session do you prefer? Check all that apply
You talk and I listen
We both take turns talking and listening
You prefer I take the lead in our conversation
You would like me to provide further insight into your situation
You would like a nondenominational prayer at the end of your session
You prefer to take the lead in our 2-way conversation
Please share any event, situation, or problem (if any) that may contribute to your need for a counseling session.
Your answer
Terms of Service
Full Disclaimer:
Click Here
Website Policy:
Click Here
Counseling Session Agreement:
Click Here
Customer information
After you have read the Terms & Conditions, Website Policy, and Counseling Session Agreement, complete your information below to confirm that you have read, understood, and agree to each terms of service.
Name (First, Last)
*
Your answer
Date:
*
MM
/
DD
/
YYYY
City, State
*
Your answer
How do you prefer to be contacted for a reminder about your invoice sent and upcoming counseling appointment? Please check all that apply.
*
Email Only
Text Message Only
Both Email and Text
2 days before your appointment
1 day before your appointment
1 hour before your appointment
30 minutes before your appointment
1 reminder only
More than 1 reminder
Required
If you want a text message reminder, type your mobile phone number below. You will receive a text from (631) 306-4203. Ex: (area code) 123-4567
*
Your answer
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