Name (who is filling out this form) *

First Name

Last Name

Name of client (e.g. child/self) *

First Name

Last Name

Select how Synergy Speech can help: *

Do you want to improve Receptive Language Skills (eg. listening; following instructions; understanding)

Do you want to improve Expressive Language Skills (eg. word finding; using grammar in words and sentences; using complete sentences; telling stories clearly)

Do you want to improve Speech Skills (eg. saying sounds clearly; saying speech sounds the correct way; speaking clearly in words and sentences; stuttering and repeating sounds words and phrases)

Do you want to work on your Voice Skills (eg. diagnosed voice disorder; seen by ENT specialist; improve voice projection; mold your sound to be more masculine/ feminine/ gender neutral; husky, croaky voice)

Do you wish to improve problem solving and social interaction abilities (eg. staying calm and working through problems; managing big emotions; working with others in groups socially and at work/ school and home)

Do you wish to improve reading and writing skills?

Have your received a formal diagnosis (eg. Dyslexia; Auditory processing disorder; learning difficulties; Autism Spectrum Disorder; Intellectual Disability; Stuttering; Hearing Impairment; other)