Speech Services Form

Date:

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.