Please fill out the inquiry form below to be added to the Speech Language Therapy Waitlist. Name * First Name Last Name Child's Name * First Name Last Name Child's Date of Birth or Due Date if inquiring pre-birth * MM DD YYYY Phone * (###) ### #### Email * What city do you live in? * What school/daycare does your child attend? * Does your child have a current diagnosis (e.g. Autism Spectrum Disorder, language delay, Down Syndrome, etc.)? * Has your child had a speech and language assessment completed in the past? If so, when and by whom? * Please indicate the areas of concern you have for your child's speech and language development you would like us to support, * Has your child had their hearing screened in the last year? * Yes, they passed. Yes, they failed. No Please select the method you would like the services to be provided. * In person at The Village YXE (324 Packham Avenue) Online Both How often are you interested in having sessions? * Weekly Biweekly Monthly As recommended by the SLP Any specific information we need to know about scheduling (e.g. available days, optimal times, etc.)? * Is there any additional information you feel that we should know in order to support your child's speech and language development? * Thank you for your inquiry!You have been added to the waitlist.You will be contacted by The Village YXE admin when an appointment comes available.