Contact - Key to Speech

Name of parent(s)

Name of child/client*

First Last

Date of Birth*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Phone*

How did you hear about us?*

Reason for consulting our clinic*

I/My child has difficulties with (please check all that apply):*

I/My child has difficulties with (please check all that apply):

Preferred Language*

I would prefer:*

Questions/Comments

I would like to add myself or my child to the horse-assisted speech-language therapy (Hippotherapy) waitlist.*

I would like to add myself or my child to the horse-assisted speech-language therapy (Hippotherapy) waitlist.

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