Speech Services Form

Speech Services

Date:

Child's Name:

Age:

Parents Name:

Telephone:

Home Address:

Is your child receiving speech therapy in school?

YesNo

If you answered YES, please include the following information:

Name of therapist:

School:

Number of times per week:

Length of therapy sessions:

Individual or group therapy:

If group, how many children in the group:

Does your child receive any speech therapy other than in the schools?

YesNo

If you answered YES, please provide the following information:

Agency providing therapy:

Name of therapist:

Number of times per week:

Length of therapy sessions:

Individual or group therapy:

If group, how many children in the group:

**It is important that you list all speech therapy services that your child presently receives to avoid any complications at a later date.