New Client Enquiries

Please complete this form — it’s quick, easy, and secure.

We will aim to contact you within five business days to discuss our availability and next steps.

Name

Organisation / Role

(if applicable)

Email

Phone

(###)

###

####

Client’s Name

Client’s Date of Birth

MM

DD

YYYY

Current Diagnoses

(Optional or required, depending on preference – e.g., Autism, ADHD, Dyslexia)

Potential Goal Areas

(E.g., language development, reading support, behaviour, etc.)

Reason for Referral

Preferred Services

Speech Therapy

Dyslexia Tutoring / Literacy Support

Speech or Language Assessment Services

Additional Information