SLHC- Application

Speech-Language-Hearing Clinic Application

Fill out an online Request for Application for the Speech-Language-Hearing Clinic services.

1.Client's Name
3.Date of Birth
4.If a minor, parent's name.
5.Address line 1
6.Address line 2
10.Home Phone
11.Cell Phone
12.Business Phone (optional)
13.Email Address (optional)
14.If sufficient referral information is available from a previous speech and language clinic evaluation, an evaluation at our clinic will not be required. Evaluations that are more than one year old will need to be updated. Evaluations are to be completed and a report on file before treatment begins. Please indicate if a diagnostic evaluation is needed:*
15.Please describe your speech-language concerns.
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