Patient Information

MM slash DD slash YYYY
MM slash DD slash YYYY
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.

Let's Talk

Contact Us

Lorem ipsum dolor sit amet, consectetur adipiscing elit sed do eiusmod tempor incididunt ut labore.

Give Us A Call

(941) 586-5529

Send A Message

Use The Form To The Right

Come Visit Us

(941) 586-5529