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Referral Form

At our clinic, we aim to make the process of accessing speech therapy services as seamless as possible. To get started, simply fill out our referral form online, which allows us to better understand your inquiry. We want to reassure you that a doctor's referral is not required; any parent or guardian can submit a self-referral. The journey towards improved communication skills begins here!

Parent/Guardian's Full Name*

Email*

Phone*

Address

Child's Full Name*

Child's Date of Birth

What Concerns Do You Have For Your Child's Speech and Language *

Pronunciation

Making Sentences

Understanding Language

Communication

Stuttering

Non-Verbal

Unsure

Other

Has Your Child Seen A Specialist For Speech In The Past?

No, this is their first time

Yes, recently (Within the past 4 months)

Yes, a while ago (Over 4 months ago)

Unsure

Language(s) Spoken at Home

How Did You Find Out About Our Clinic?*

Privacy and Consent Notice

By submitting this self-referral form, you consent to The Speech Solution Centre collecting and storing the personal information you provide within our secure database. The information submitted through this form will be used solely for the purpose of responding to your inquiry, contacting you regarding potential services, and providing you with relevant information about our clinic and services. Your information will not be used for unrelated purposes. By submitting this form, you acknowledge that you have read and understood this notice and consent to the collection, storage, and use of your information for the purposes described above.

Thank you for submitting your referral form! We appreciate your interest and will be in touch with you within 2 business days. If you have any questions in the meantime, feel free to reach out via email.

Email

info@speechsolutioncentre.ca

Visit

2141 Kipling Avenue

Unit #10

Rexdale

Etobicoke, Toronto
M9W 4K8

Call

+1-416-792-1575

Follow

416-792-1442

Fax

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