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Parent/Guardian Name*

Child's Name*

Email Address*

Phone Number*

What are your main concerns? (Check all that apply)

Speech/Articulation (saying words clearly)Expressive Language (getting words out)Receptive Language (understanding language)Feeding/Eating and SwallowingBreathing issues like chronic mouth breathing or obstructive sleep apneaThumb/finger sucking, nail-biting, and bruxism (teeth grinding/clenching)Orofacial Dysfunction (tongue thrust, incorrect swallowing, tongue-tie and speech issues related to muscle weakness)Literacy (reading and writing)Cognitive Communication (problem solving, skills required to manage every day tasks)Alternative Communication (methods/strategies to replace spoken language)Developmental Milestones (walking, talking, dressing self, counting)Fine Motor/Using hands (handwriting, scissors, dressing skills)Gross Motor (playground participation, ball skills, coordination)Sensory ProcessingPlay and Social Skills (making friends, adapting to new situations)Executive Functioning (memory, attention, concentration)Emotional Regulation (outbursts, irritability, defiance)Managing Symptoms (feeling overwhelmed, worried, sadness, anger)Trauma/Life Changes (abuse, neglect, bullying, moving, death)Self Harm (risky behaviors, self-injury)Assistance navigating community supports/I.E.POther (please describe below)

Additional Details / Other Concerns