Parent/Guardian Full Name(Required) First Last 🔒 Important Notice About Your Privacy I agree to the privacy policy.Please do not share any sensitive or personal health information on this form. SpeechAve uses a dedicated, HIPAA-compliant client portal for all confidential intake and communication. Once we receive your request, we’ll provide a secure link to complete your intake safely.Parent/Guardian Email(Required) Parent/Guardian Phone👶 Child’s AgeChild’s Age (in years) 🧠 Speech & Developmental Concerns Not talking yet Hard to understand Limited vocabulary Trouble following directions Not responding to name Late with speech milestones What are your current concerns? (Please select any that apply)📄 Has your child had a hearing screening?NoYesNot sure📄 Has your child received any previous evaluations or therapy?NoYes🗣️ Do you have any additional concerns or observations you'd like to share about your child's communication skills?This could include anything about how your child speaks, listens, plays, interacts with others, or expresses their needs. 💡 Optional - Would you like to receive a free developmental milestone checklist? No Yes ✅ Consent & Submission I consent to be contacted by SpeechAve for scheduling and follow-up
