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Care 2 Learn
Speech-Language Therapy Assessment Request

Please complete the assessment request if you are interested in therapy with Care 2 Learn. Once we receive this request we will invoice you via email for the cost of the assessment and consultation. The fee for the assessment and consultation is $150. The invoice will state that you may pay via credit, debit, or check mailed to:

Care 2 Learn Tutoring
PO Box 8574
Fort Wayne, IN 46898-8574

For more information, please contact a Care 2 Learn team member at info@Care2LearnTutoring.com.

The Invoice for $150 will be sent to the eMail address listed below.
Agreeing to participate in the assessment & consultation does not obligate you to future therapy with Care 2 Learn.


All fields marked with a * are required:

Student First Name*
Student Last Name*
Date Of Birth*
Age*
School*
Subject*
Location Desired:*
Grade Level*
Days Available:*
Please choose at least all days you are available to complete a consultation and have your child complete an assessment. 		Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Notes about Schedule:
Please be specific on times for days selected, extra curricular events scheduled, how soon would you like assessment scheduled, times available for consultation after testing, etc.

while the assessment and consultation times may vary, the average length of time is roughly 2 hours.
Days Available:*
Please choose at least all days your child is available for therapy per week.
(Therapy typically takes place on Mon & Weds OR Tues & Thurs) 		Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Times Available for Therapy:*
(please select ALL times that may work for the student) 		2:45-3:45
3:00-4:00
3:30-4:30
3:45-4:45
4:00-5:00
4:30-5:30
4:45-5:45
5:00-6:00
5:30-6:30
5:45-6:45
6:00-7:00
Is Therapy preferred during the day?:*




If you prefer therapy during the daytime, please specify times that would NOT work during your selected therapy days. 		Yes
Yes, Not Preferred
No
Diagnosed with Learning Disabilities?* Yes
No
Never Tested
If you answered Yes, what is your child's diagnosis?*
Is your student receiving Special Services at School?*
If you answered Yes, please specify what special services are being rendered.*
Currently Receiving Speech Therapy:
Where:
How Often:
Previous tests Performed:
Diagnosis:
Qualities and Characteristics you desire in a therapist?
How did you hear about us?
If Doctor Referral, Please List Referring Physician:
Parent Name*
Please provide your email contact info*
The Invoice for $150 will be sent
to this eMail Address.
Please provide your physical address* Address:


City:


State:


Zip Code:
Please provide a contact phone*
         
Agreeing to participate in the assessment & consultation does not obligate you to future therapy with Care 2 Learn.

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