Rainbow Speech Intake Form

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Hello and welcome to Rainbow Speech! Please fill out our General Intake Form (below). Once received, our staff will review your information and will be in contact with you in approximately 3-5 days. We appreciate your patience. We look forward to connecting with you and seeing what is possible. Thank you!

Name *

Email *

Phone *

Address (optional)

Reason for Seeking Our Assistance: *

Tell us what is going on.

Client Age Group: *

Infant/Toddler (age 0-3 years)

Preschool/Kinder (age 4-5)

Elementary (1st - 5th grade)

Middle School (6th - 8th grade)

High School (9th - 12th grade)

Young Adult

Adult

Elder

Presenting Challenge(s): *

I am difficult to understand (sounds aren't right, mumbling, mouth is hard to move, etc.)

I have difficulty understanding others (following directions, word meanings, auditory processing)

I have difficulty expressing myself (grammar, word-finding, etc.)

Talking isn't always smooth for me (stuttering or voice challenges)

I use or might need to use a communication device to express myself (AAC or Assistive Technology)

Eating is tricky for me (feeding or swallowing)

I have a hard time making and/or keeping friendships (social pragmatics)

I have a hard time paying attention and organizing my thoughts and/or work (executive functioning and language processing)

Other:

Required

How concerned are you about the presenting challenge? *

Not worried

Very concerned

Preferred Contact Method *

Phone

Mail

Other:

Required

Additional Questions or Comments:

Submit

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