Get startedFill our the consultation request form below to get started. Client Name * First Name Last Name Client Date of Birth * MM DD YYYY Client Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Today's Date * MM DD YYYY Are you a parent or guardian requesting an appointment for your child? * Yes No Name of Person Completing Form * Relationship to client * Contact Phone number * (###) ### #### Email * Hearing test available for review within 12 months? * Yes No Has the client completed prior CAPD testing? If yes, when, and by what provider? What were the results? * Has the client completed a neurodevelopmental evaluation by a psychologist? If yes, when, and by what provider? What were the results? * Has the client been evaluated by any of the following professionals? * Speech therapy for articulation/sound production errors/voicing/swallowing Speech therapy for expressive or receptive language Physical Therapy Occupational Therapy Reading Interventionist Tutor Special Education Department at school Optometrist Ophthalmologist Ear, Nose, and Throat Physician Counselor Social Worker Psychologist Psychiatrist Other Audiologist Has the client been release from any of the above service providers or is on an "as-needed" basis? * Speech therapy for articulation/sound production errors/voicing/swallowing Speech therapy for expressive or receptive language Physical Therapy Occupational Therapy Reading Interventionist Tutor Special Education Department at school Optometrist Ophthalmologist Ear, Nose, and Throat Physician Counselor Social Worker Psychologist Psychiatrist Other Audiologist Please list the name, medical group/clinic, phone number and address of the current providers as well as dates of services. * Do you have access to high-speed internet and stereo, wired headphones or earbuds needed for testing? * Yes No Thank you for contacting Kentucky Sound Foundations, LLC.! Your submission form was successfully submitted. We will respond to your request as soon as possible, typically within 48 hours.
