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Client & Parent Details

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Client Details

Parent/Guardian 1 Details
Please enter details about the Parents/Guardians of the Child separately. Please enter details below about the primary parent, or the parent who is filling out this application.

Parent/Guardian 2 Details
Please enter details about Parent/Guardian 2 of the Client

Family History

Page 2

Page 2

Client Speech & Language History

Page 3

Medical and Developmental History

Page 4

Educational & Social History

Page 5

Client Demographic Information

Consent & Electronic Signature

Please type your full legal name

Please enter today's date
Financial Assistance

Teen Self-Report Survey

This form is intended for the client to fill out. Please have your teen fill out this self report survey and do not fill it out on their behalf. If you need to, you may save the form and resume later.
Please read each statement and select the choice that most closely matches how the statement applies to you.