* Required

Student's First Name*required

Student's Last Name*required

Student's Nickname

Date of Birth*required (mm/dd/yyyy)

Age*required

Gender*required

Please Select…MaleFemaleOther

Grade*required

Please Select…Pre-KKindergarten123456789101112

If you selected "other", feel free to specify gender identity here (optional)

School Name

City*required

State*required

Please Select…AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Parent 1:

First Name*required

Last Name*required

Primary Email Address*required

Preferred Phone*required

Parent 2:

First Name

Last Name

Primary Email Address

Preferred Phone

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Which therapy/services are you interested in receiving*

Speech-Language Therapy  Occupational Therapy  Both 

Has your child received Speech or OT services in the past?*

Yes  No 

If yes, please provide any relevant details (how long ago, how often, etc.)

What goals has your child been working on and/or what would you like services to focus on?*required

Is there anything our team should know about your child to help us design a successful session?

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Please share with us how you learned of AIM Academy’s Tutoring Center:

Please send a confirmation email to the address below*: