Request for Individual Speech-Language Therapy

Name of Student:

School:

Grade:

Class:

My child is registered in:

SLP:

Sessions are funded by:  CCSD Independent Schools Rocky View Parent Fees

Other School Board:

My child presently attends:  Individual P3 Group P4 Class

Please indicate if your child is receiving other speech therapy:  at school private provider

Parent(s) Request: (please explain why you and/or your child would benefit from individual therapy)

Rate: PREP Member Rate $90/session

Payment: Parents are invoiced monthly and payments are due on receipt of invoice. Parents can request a cost share or waiver of fees due to financial circumstances.

Request for Day/Time: My child and I are able to commit to appointments on:

Day of week:  Mondays Tuesdays Wednesdays Thursdays Fridays

Time:  AM PM (no Fridays available)

This application will be presented by Bonnie Moschopedis, PREP 3 & 4 Coordinator at the PREP 3 or PREP 4 team meeting. Our goal is to meet your request. However, due to the limited # of openings, PREP can only offer parents what is available. Parents can decline the opening offered and apply again at a later date.

Thank you for your request.

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