Student Information

Student First Namerequired

Student Middle Name

Student Last Namerequired

Student Date of Birthrequired

mm/dd/yyyy

Student Gender*

female male

If other, please explain.

Does the student currently attend The Joy School?*

Yes No

Student's Current Schoolrequired

Contact Information

Prefix*

Ms. Mrs. Mr. Dr.

Parent First Namerequired

Parent Middle Name

Parent Last Namerequired

Suffix

Street Addressrequired

Cityrequired

Staterequired

Zip Coderequired

Primary Phonerequired

Ext.

Phone Type*

Cell Work Home

Primary Email Addressrequired

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

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 contact Meredith Hibbetts, Speech Language Pathologist, at mhibbetts@thejoyschool.org.

Without parental agreement to the Therapy Policies, we cannot 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