AIS Interest form
Please fill out this form if you are interested in working with AIS in speech therapy.
I am a current or past client of AIS
I am a new client of AIS
Current or Previous Clients:
You have indicated you're a current or previous client. Please contact your therapist or the AIS office at email@example.com to get an invitation to apply for Financial Assistance!
Client Date of Birth
Referred by Friend/Family (Please specify)
Partner Referral (Please specify)
Referred by Other:
Please describe your concerns and goals for speech therapy:
I would like to apply for financial assistance through AIS to help pay for my treatments.