Therapy Inquiry Form

Your Name *

First Name

Last Name

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Additional Address (school/daycare if services will not be provided in-home)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

We are interested in: *

Evaluation

In-person Services

Virtual Therapy

Other

Select the following response(s) that best describes your child: *

They are a gestalt language processor.

We believe that they are a gestalt language processor, but we're not sure and would like some more information.

They are an analytic language processor.

They are an AAC user (currently using a robust AAC system such as a communication program on an iPad).

They are not currently using a robust AAC system, but we think that they would benefit from one.

We are available on the following days in the morning (9:00am-12:00pm) for services (check all that apply) *

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Unavailable during these times

We are available on the following days in the afternoon (12:00pm-5:00pm) for services (check all that apply)

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Unavailable during these times

Please check the box to confirm that you have reviewed the "Helpful Information" and "Services" pages on our website and understand the services we offer and our current rates. *

I confirm that I have read the Helpful Information and Services pages.