Dear Parent and/or Prospective Client,
The following forms have been made available on-line for your convenience. Please contact Jennifer Buck, Administrative Assistant to the Speech-Language Pathology Clinic, prior to completing any of the forms. All forms are in PDF format. Thank you!
Speech and Speech-Language Evaluations:
After speaking with Ms. Buck, the following items must be mailed to her attention in order to reserve an appointment for an evaluation.
1. Parent Questionnaire (Adult Questionnaire if over the age of 18)
2. School/Teacher Questionnaire (not necessary for adults)
3. A non-refundable deposit
• Speech and Language Evaluation: $300
• Speech Evaluation: $100
School Questionnaire Ages 12-35 months
School Questionnaire Preschool
School Questionnaire Grades K-5
School Questionnaire Grades 6-12
Parent Questionnaire
Adult Questionnaire
Speech-Language Intervention Services:
All clients must have participated in an evaluation prior to beginning therapy. If an evaluation has been completed elsewhere, after speaking with Ms. Buck, please complete the above-posted parent (or adult) questionnaire and teacher questionnaire and mail to her attention with a copy of your child’s evaluation. If the evaluation has been completed at this facility, you are a returning client, or if this information is already on file due to enrollment in another Atlanta Speech School program, please complete the appropriate registration form below and give it to Ms. Buck or your therapist on or before your first day of therapy. Thank you!
Therapy Registration Forms:
Child Speech Registration Form - Academic Year
Child Speech Registration Form - Summer Program
Adult Speech Registration Form - Academic Year
Adult Speech Registration Form - Summer Program
Please direct all questions or comments to Jennifer Buck, Administrative Assistant to the Speech-Language Pathology Clinic via email or at 404-233-5332 ext. 3106.