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Speech Therapy Application

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This field is for validation purposes and should be left unchanged.
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Name*
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Address*
Does the applicant have a medical diagnosis? (i.e., Autism, Down Syndrome, Learning Disability, Dyslexia, Stroke/Aphasia, Parkinson’s, etc.)*
Has the applicant been a client at RRC in the past?*
Is the applicant currently receiving speech therapy at another facility?*
Has the applicant received speech therapy at another facility in the past?*
Agreement*
Please Check Box above agreeing you understand

If you have any questions or concerns about our application please call us at 662.842.1891