Do you feel your child may have a communication delay?

If so, a free 20 minute phone consultation is offered to discuss your questions and concerns. From there, we will discuss the next steps, such as a speech-language screening or evaluation. Feel free to use the “contact us” form, or the screening request form below.

Note: I will only gather parent/guardian contact information. Pep Talk will contact you (in a HIPAA compliant manner) to gather more information about your child.

Screening Request Form

Please complete this form in order to request a speech-language screening from Pep Talk, PLLC.

Child's First & Last Initials ONLY

First Name

Last Name

Child's School

Grade, Teacher, or Class-Age

Parent/Guardian Name

First Name

Last Name

Phone

(###)

###

####

Please describe any specific concerns you may have.

Consent

I hereby give consent to have my child, listed above, screened by Pep Talk, PLLC. Unless indicated below, I further authorize Pep Talk, PLLC to discuss the results with my child's teacher.

Date

Enter Today's Date

YYYY

I do not authorize Pep Talk, PLLC to discuss the results with my child's teacher.

I authorize Pep Talk, PLLC to discuss the results of the screening with my child's teacher.

Do you feel your child may have a communication delay?

If so, a free 20 minute phone consultation is offered to discuss your questions and concerns. From there, we will discuss the next steps, such as a speech-language screening or evaluation. Feel free to use the “contact us” form, or the screening request form below.

Screening Request Form

Katie Norberg

M.S.Ed. CCC-SLP