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Child's Name:required

First Name

Last Name

Child's School:required

If your child attends the Atlanta Speech School, please note the specific program

Is your child a: (Please select all that apply)required

Current Client

Former Client

New Client

Parent / Caregiver Name:required

First Name

Last Name

Parent / Caregiver Email Address:required

Parent / Caregiver Phone Number:required

Relationship to Child:required

Mother

Father

Legal Guardian

Other

Child's Date of Birth:required

Must contain a date in MM/DD/YYYY format

Gender:required

Male

Female

Child's Age:required

Child's Rising Grade (2026-27 school year):required

Has your child received one of the following evaluations: (Please select all that apply)required

Please select the service(s) you are interested in: (Please select all that apply)required

Did your child receive a recommendation for clinic services? If so, please explain:required

Areas of Concern:

Please provide your child's teachers email below if you give our office consent to send a teacher questionnaire:

Please note: Certain clinic services require submission of a teacher questionnaire.

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