Fillable Online Under general supervision, supervises the 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the CLIENT INFORMATION section. Enter your child’s name, date of birth, age, and gender. Provide your name as a parent or guardian, along with your address, city, state, ZIP code, phone number(s), and email(s).
3. In the SCHOOL INFORMATION section, indicate whether your child is currently attending school by selecting 'Yes' or 'No'. If 'Yes', provide the school name, address, and phone number.
4. Move to the THERAPY HISTORY section. Indicate if your child is receiving individual speech therapy and provide details about their speech-language pathologist (SLP) if applicable.
5. Answer questions regarding any diagnoses related to Childhood Apraxia of Speech and other developmental conditions. Include information about additional therapy services your child may be receiving.
6. Finally, review the understanding statements at the end of the form. Ensure you sign and date where indicated for both parents/legal guardians.

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