*Please enter your child's name.
Child's First Name
Child's Last Name
*What is your child's gender?
*Please provide your most current contact information:
Your First & Last Name
Your Relationship to the Child
Best Phone Number
Alternate Phone Number
Email
*What is your child's home address?
Street Address
City
Zip Code
Major Cross Streets
*Which funding source are you planning on using to pay for speech or feeding therapy? Check all that apply.
*Is your child approved for speech therapy services through DDD/ALTCS?
*Where would you like speech or feeding therapy sessions to take place?  Check all possible options.
*When scheduling your child's therapy, choose a time that will be available for at least the next 6 months. Which time blocks will work for you? (please note, speech therapy sessions are 1 hour long)
8:30 - 10:30am10:30am - 12:30pm1:00 - 3:00pm3:00 - 5:00pm
Monday
Tuesday
Wednesday
Thursday
Friday
Explain any scheduling limitations here, if needed:
*Please answer the following questions regarding your child:
What are your child's areas of strength?
What types of things motivate your child?
Are there any behavior challenges we should be aware of?
Is your child currently receiving speech therapy? If so, where?
Is your child currently receiving any other AZA United services? If so, which ones?
How is your child currently communicating? (verbal, AAC device, etc.)
Is there anything else you would like us to know?