CONTACT US

Please complete the following form as completely and precisely as possible (ex. full name and address, e-mail/phone number).
This will allow our team to contact you and add you/your child to our waiting list.

Name of parent(s) (if inquiring for your child)

Client/Child's First Name

Client/Child's Last Name

Phone

Date of Birth

Email

Address

I/My child has difficulty with

Speech/Articulation (Speech Sounds)

Language (Comprehension and/or Expressive Language)

Reading and Writing

Social Communication

Homework

Swallowing

Voice/Chronic Cough

Language(s) spoken

French

English

Bilingual

Other

Reason for requesting consultation

Thank you.

A member of our team will be in contact with you shortly.

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