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TheraFriends Speech-Language Interest Form
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* Indicates required question
Email
*
Your email
Caregiver Name
*
Your answer
Caregiver E-Mail Address
*
Your answer
Caregiver Phone Number
*
Your answer
Address
*
Your answer
Child's Name
*
Your answer
Child's Age
*
Your answer
Child's Pronouns
(more info:
https://www.mypronouns.org/
)
*
Your answer
Will you be utilizing NCSEEA grant funds for services?
*for more information: https://www.ncseaa.edu/
*
Yes
No
Service Requested
*
Speech-Language Group Sessions
Speech-Language Individual Sessions
Required
Preferred Location
Durham
Chapel Hill/Pittsboro
Cary/Apex
Raleigh
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Preferred Days - check all that apply
Monday
Tuesday
Wednesday
Thursday
Preferred Time Ranges (group will be 1 hour long) - Check all that apply.
Morning (8:30am -11:00am)
Midday (11:00am -1:00pm)
Afternoon (1:00pm - 3:00pm)
After School (3:00pm - 5:00pm)
What are your child's greatest passions/interests?
Your answer
Main Areas of Support/Priorities
*
Your answer
Is your child currently receiving therapy services?
*
Yes
No
If yes, which therapy services are they receiving and where?
Your answer
How did you hear about us?
*
Your answer
Send me a copy of my responses.
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