Therapy Consultation

Name *

Patient or Family Member Name

First Name

Last Name

Phone *

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I'm interested in help with..... *

Oral and Facial Weakness/Asymmetry

Prolonged Chewing and Meal Time

Feeling of Foods Sticking in Throat

Coughing or Choking on Liquids

Difficulty Understanding Others' Talk

Difficulty Understanding Needs and Wants

Challenging in Expressing Needs and Wants

Slowed or Difficulty Word Finding

Poorly Coordinated/Sequenced Speech Movements

Slurred Speech

Voice and Speech Problems with Parkinson's or related disease

Other Speech or Language Problems

Voice Problems

Cognitive Deficits