Intake Form
Please complete this secure form to the best of your ability. The information you provide will help the speech therapist form a treatment plan for your child.
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Email *
Child’s Name (First, Middle, Last)  *
Child's Birthdate *
MM
/
DD
/
YYYY
Name of person completing form and relation to child *
Home Address, City, State, Zip *
Phone number *
Email address *
Parent / Guardian #2 (Full Name and Relation)
Phone number
Address, City, State, Zip code
Email address
Who does the child live with?
Who does the child spend the most time during the day with? *
What is the primary language in the home? *
Are any other languages spoken? If so, what language and who speaks it?  *
If yes, what languages does the child understand? Which language does the child prefer to speak at home?
We offer services in the home, virtually through a secure online format, in schools, daycares and out in the community (ex. park, library). Where are you interested in receiving services? *
Required
What are your preferred days and times for appointments? Information you provide here will assist with scheduling. Please note that our hours are 8:30am - 4pm Monday through Friday. 
Morning (9am- 11:59 am)
Afternoon (12 pm- 4:00 pm)
Monday
Tuesday
Wednesday
Thursday
Friday
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Additional scheduling preferences:
Is your child participating in Virginia's K-12 Learning Acceleration Grant. *
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