Myofunctional Therapy Intake Form | Los Gatos, CA | Strategies for Success, Inc.

Date - must be mm/dd/yyyy format * Required
MM slash DD slash YYYY
Patient’s First Name * Required
Patient’s Last Name * Required
Date of Birth - must be mm/dd/yyyy format * Required
MM slash DD slash YYYY
Address * Required
Street Address Address Line 2 City State ZIP Code
Phone * Required
Preferred contact method? * Required
- Phone
- Email
Email * Required
If you are a parent or guardian, please fill out the following.
1st Parent/Guardian Name
Address
Street Address Address Line 2 City State ZIP Code
Phone
Email
2nd Parent/Guardian Name
Phone
Email
Referring Doctor * Required
Reason for Referral * Required
- Tongue Thrust
- Short Labial Frenulum
- Short Lingual Frenulum
- Articulation Concerns
- Postural Imbalances
- Other (provide details below)
Additional Details * Required

Specialized Speech and Language Therapy

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