Parent's Name

Email *

Phone *

Child's Name *

Child's Date of Birth *

Which Speech Group Would You Like To Attend? *

Wednesdays 3-4pm (8-weeks)

Wednesdays 4-5pm (8-weeks)

Tell Us A Bit About Your Child *

Does your child currently receive speech therapy? *

Y

N

Has your child been diagnosed with a speech sound disorder? *

Y

N

What goals do you have for your child's speech? *

What else would you like me to know about your child's speech? *

Total cost per group is $400.

$200 deposit required to hold your child's spot.

Your card will be charged the remainder of the balance two weeks before start date.

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