Patient Name: *

First Name

Last Name

Patient DOB: *

MM

DD

YYYY

Patient Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Patient's Primary Physician *

First Name

Last Name

Patient's Primary Physician's Phone Number *

(###)

###

####

Guardian Name: *

First Name

Last Name

Phone: *

This phone number will be used to create a Klara account. Klara is our HIPAA compliant messaging app.

(###)

###

####

I am interested in receiving the following therapy services: *

Check all that apply:

Speech Therapy

Feeding Therapy

Occupational Therapy

I am unsure

Concerns for adult:

Select all that apply:

Speech/Communication

Cognition

Voice

Fluency

Dysphagia/Feeding

Accent Modificiation

Concerns for child

Select all that apply

Speech sounds

Grammar/Vocabulary/Sentence Length

Following directions

Fluency

Alternative communication or communication device

Swallowing

Chewing

Picky eating

Feeding themselves

Weight gain

Breast or bottle feeding

Tongue/Lip tie

Fine motor skills

Self-care

Behavior

Motor movement

Sensory integration

Select any previous evaluations received: *

You will be asked to provide the selected evaluation reports. If therapy evaluation reports are less than one-year old, you may be able to begin therapy without an evaluation.

Speech therapy evaluation

Occupational therapy evaluation

Developmental/Neurological/Educational evaluation

None