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Fortis Summer Speech Therapy
Please complete the interest form below to determine availability and appropriateness for placement. We will contact you as soon as possible to discuss options!
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* Indicates required question
Child's name:
*
Your answer
Child's age & grade:
*
Your answer
Does your child reside in Maryland?
*
Yes
No
Parent/guardian name:
Your answer
Parent email:
*
Your answer
Parent phone number:
Your answer
Child's primary IEP goals:
*
Early Intervention/Language Development (IFSP)
Articulation & Phonology
Oral Language (listening, speaking)
Written Language (reading, writing)
Pragmatic (social) Language
Fluency (stuttering)
Required
Availability (please select all that apply)
*
Monday afternoon
Wednesday morning
Wednesday afternoon
Thursday morning
Friday morning
Required
If you are interested in specific children and/or siblings being included in your group, please list their names.
Your answer
Are you interested in in-home group therapy for at least two children?
Yes
No
Clear selection
If interested in in-home therapy, please list your zip code.
Your answer
Are you interested in individual speech therapy for your child?
Yes
No
Clear selection
If interested in individual speech therapy, please select your preference.
Virtual
In-home
No preference
Clear selection
Are you able to provide a copy of your child's IEP goals prior to our first session?
Yes
No
Clear selection
Please provide any additional information you feel may be helpful for determining placement.
Your answer
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