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Patient Information

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What are main concerns? Please check ALL that apply:

Speech-Language-Hearing History

Do you feel your child has a speech problem?
Do you feel your child has a hearing problem?
Has your child ever had speech-language therapy?
Is there a language other than English spoken in the home?
Does the child speak the language?
Does the child understand the language?

Does your child:

Repeat sounds, words, or phrases over and over?
Understand what you are saying?
Retrieve / point to common objects upon request (ball, cup, shoe)?
Follow simple directions ("Shut the door", or "Get your shoes")?
Respond correctly to yes/no questions?
Respond correctly to who/what/where/when/why questions?

Financial Information - Mother

Financial Information - Father

Other Monthly Income

Financial Liabilities/Monthly Expenses

This field is for validation purposes and should be left unchanged.

Note: All information supplied herein will remain part of the confidential records of Sertoma Kids Inc and will not be distributed to or released to anyone outside this organization for any reason.

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(941) 586-5529

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Come Visit Us

(941) 586-5529

About Sertoma Kids

Sertoma Kids offers treatment for speech, language, literacy, and social skills. Our experienced therapists develop the most comprehensive care plan that is specific to the individual child and his/her needs.
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Contact Information

Call Us

(941) 228-1062

FAX

(941) 257-6041

Email Us

speech@sertomakids.org

Visit Us

2750 Stickney Point Rd Suite 210 Sarasota, FL 34231

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