Waitlist Application PlayTalkGrow Speech Therapy Waitlist ApplicationThank you so much for your interest in PlayTalkGrow Speech Therapy. We currently have a waitlist for after-school services. Please complete the application below to provide us with information about your child and the support you are looking for. You will be added to the waitlist if your child is a match for the services we offer and our specialty areas.Your Email Address(Required) Your Phone(Required)Best Time to Call You(Required)Select A Time12:00 am12:30 am1:00 am1:30 am2:00 am2:30 am3:00 am3:30 am4:00 am4:30 am5:00 am5:30 am6:00 am6:30 am7:00 am7:30 am8:00 am8:30 am9:00 am9:30 am10:00 am10:30 am11:00 am11:30 am12:00 pm12:30 pm1:00 pm1:30 pm2:00 pm2:30 pm3:00 pm3:30 pm4:00 pm4:30 pm5:00 pm5:30 pm6:00 pm6:30 pm7:00 pm7:30 pm8:00 pm8:30 pm9:00 pm9:30 pm10:00 pm10:30 pm11:00 pm11:30 pmParent/Caregiver(s) Name(Required) First Last Best Email for Patient Portal(Required) Child's Full Name (as shown on insurance policy)(Required) First Last Child's Date of Birth(Required) What are your primary concerns? Check all that apply. (Please note that we are a speech therapy clinic only - we do not have occupational or physical therapy)(Required) Clarity of speech Difficulty pronouncing speech sounds Difficulty forming sentences Decreased vocabulary size Late talking Difficulty following directions Stuttering Language processing Feeding concerns Social difficulties I'm not sure... Other Why are you seeking an evaluation/speech therapy for your child?(Required)List both Primary and Secondary Insurances your child has.(Required)Does your child have any medical diagnosis?(Required)Preferred days/times for recurring therapy sessions (please feel free to provide us with as much detail as possible regarding your child's schedule & availability) *(Required)Is your child in school? If yes, please let us know their school schedule.(Required)Please feel free to add anything else you'd like us to know about your child.
