Intake Form

Request a Speech screening

Patient's Name(Required)
Date of Birth
Parent/Guardian Name if Patient is under age 18
Can the office text this number?
How did you hear about us?
Preferred time of day for sessions
All sessions at Speech Sessions are delivered via telepractice. You will need a laptop, desktop computer, or tablet. You will also need a camera and microphone. Many laptops will have these features built-in. We do not recommend using a cell phone due to limitations for sessions. Do you have access to reliable internet, camera, and microphone?
Does the patient have an IEP (Individualized Education Plan)?

Thank you for completing this online form.

A representative from Speech Sessions will contact you to setup your free consultation and complimentary screening.
This field is for validation purposes and should be left unchanged.