* Required

Student Information

Student First Name*required

Student Middle Name

Student Last Name*required

Student Date of Birth*required

mm/dd/yyyy

Student Gender*

female male

Student's Current Grade*

Pre-K Kindergarten 1st 2nd 3rd 4th 5th 6th 7th 8th Other

If other, please explain.

Does the student currently attend The Joy School?*

Yes No

Student's Current School*required

Contact Information

Prefix*

Ms. Mrs. Mr. Dr.

Parent First Name*required

Parent Middle Name

Parent Last Name*required

Suffix

Street Address*required

City*required

State*required

Zip Code*required

Primary Phone*required

Ext.

Phone Type*

Cell Work Home

Primary Email Address*required

Please select which type of therapy you are interested in*

Individual therapy services Group therapy services Unsure

Please describe your child's therapy needs and/or concerns (ie. articulation, expressive/receptive language, social pragmatics, executive functioning, etc.)*required

Desired length of therapy session*

45 minutes 1 hour 1 hour and 30 minutes Unsure

Number of days a week you would like your child to receive therapy*

1 2 3 4 5 Unsure

Days of the week you are available*

Monday Tuesday Wednesday Thursday Friday Unsure

I have read and understand the Therapy Policies*

Agree Disagree

Click here to review The Joy School's Therapy Policies.

If you have questions or concerns about The Joy School's Therapy Policies, please reach out to Elyse Trusell, Program Director, at etrusell@thejoyschool.org.

Without parental agreement to the Therapy Policies, we are unable to provide our speech and language therapy services to your child.

Testing & Documentation

You may submit copies of a recent report card or reports for any testing completed within the last two years to help give our speech-language pathologists background information about your child.

Please submit Psychological, Developmental or Educational Testing, or Report Card below (optional)

Max file size: 10 MB

Upload additional files (optional)

Max file size: 10 MB

Upload Additional Files (optional)

Max file size: 10 MB

Please send a confirmation email to the address below*: