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Rachel Madel Speech Therapy Inc.
Home
About
Meet Rachel
Meet Our Team
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Blog
Videos
Podcast
Resources
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Speech Therapy Schedule
Parent Name:
*
Child's Name:
*
Home Address
*
School:
*
School Address:
*
School Begins on:
*
Availability
Please list your child's availability between the hours of 8-6. If they are unavailable on a certain day please state "N/A". Be as specific as possible! If you have an ideal day or time please include it below but be aware we can't guarantee specific days/times. If you fill out the form and your availability changes then please contact us immediately and let us know.
Monday
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
Is your school open to doing sessions there?
Yes
No
Not sure
Is your ABA company willing to overlap?
Yes
No
Not sure
How frequently would you like services?
Weekly
2x/week
3x/week
Monthly
I'm flexible
Not sure
I would like:
*
Please check all that apply. We will do our best to accommodate.
In-Home Services
In-School Services
In-Office Services
I'm Flexible
Additional Notes
The more information you give us the better!
Thank you!