CANTO Speech TherapyCANTO SPEECH THERAPY in PORTLAND and ONLINE

speech_therapy_online_canto - testing Jan 2020 - no botton lineused Dec 2017 copy.jpg

Registration Form

Please take a moment to fill in the form.

We use this information to help us in our assessment and treatment of your child.

Please remember to submit upon completion.

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This form completed by:

Relationship to child:

Child's name

Child's date of birth

Place of birth

Sex/gender

Address

City

Province/State

Postal code

Country

Phone

Email address

Parent 1 name

Parent 1 date of birth

Parent 1 occupation

Parent 1 place of employment

Parent 2 name

Parent 2 date of birth

Parent 2 occupation

Parent 2 place of employment

Child lives with

both parents

mother

father

other

Caretakers marital status

Parents are

natural/biological

adoptive

Please list all others who live in the household (such as siblings, grandparents, nanny, atc) including their realtionship and ages

Language/s spoken in the home

Are all caretakers fluent in the language listed above? If no, please explain

Name of the school

Grade level

Language of instruction in the school

If there is a second language in the school, and not necessarily the language of instruction, please list

Insurance Provider and Insurance ID#

How did you find Canto Speech Therapy

Who may we thank for referring you

I understand that the information I supply in this form will be used for evaluation and treatment purposes only for my child. The information I provide, and have provided, is complete, accurate and up to date. Submitting this form to Canto Speech Therapy (whether signed or not) acts as my signature and affirms that I have received the Terms of Agreement - I fully understand, and agree to comply with the terms and conditions outlined in the Terms of Agreement. I consent for my child, listed above, to receive speech language pathology services in person or online from Canto Speech Therapy. Please provide your full name in the box below

Today's date

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Registration Form

Canto....focusing on the child.... because we care

Canto Speech Therapy is a long established and trusted service provider of SLP services locally and globally online.

Call Us 571.435.0676

Contact Us

“the power of speech ....

....the most powerful yet natural tool we POSSESS…

to last a LIFETIME” ©