Parent/Guardian Information *

First Name

Last Name

Phone

(###)

###

####

Child's Name *

First Name

Last Name

How would you describe your child’s typical speech and language? *

Speaks in full sentences clearly

Speaks in short phrases or sentences, but not always clearly

Has difficulty expressing themselves

Uses mostly gestures or limited words

Does your child follow 1-2 step directions (e.g., “Go get your shoes and sit down”)? *

Yes, consistently

Sometimes

Rarely

Can your child attend and participate in a small group setting for 45 minutes without frequent breaks? *

Yes, my child can focus and participate in a group

My child sometimes struggles to stay focused or calm in groups

My child has significant behaviors or needs that might make group participation difficult

Does your child know all the letter sounds (both uppercase and lowercase letters)? *

Yes, my child knows all letter sounds

My child is still learning some letter sounds

Does your child struggle with decoding (sounding out) unfamiliar words? *

Yes, often

Sometimes

Rarely or never

Please check each box to acknowledge your understanding of our program policies: *

I understand this is an educational enrichment program, not individualized therapy.

I understand all children must complete Level 1 of the program before progressing to other levels, to ensure they have the necessary foundational skills.

I understand that if my child is accepted, I am committing to the full 6-week program.

I understand there are no refunds unless the therapist determines my child is not the right fit for this group.

I understand sessions are not prorated or rescheduled for absences or missed classes unless the therapist needs to cancel in which ad additional session will be added at the end of the 6 weeks.

I agree to support my child in completing the brief homework assigned each week to reinforce learning

I understand this form does not guarantee placement. I will be contacted if my child is a good fit for the group, and an invoice will be sent at that time.