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Apply for Speech Therapy with Austin Smiles

By filling out the form below, you are signing up to be contacted for your interest in receiving free speech therapy assistance from Austin Smiles for your child. Children must be under the age of 18. Speech Therapy can be remote or in person in Austin, TX. We will reach out to applicants with more details. Spots are limited.

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Al rellenar el siguiente formulario, usted se está inscribiendo para ser contactado por su interes en recibir asistencia de terapia del habla gratuita de Austin Smiles para su hijo. Los niños deben ser menores de 18 años. La terapia del habla puede ser remota o en persona. Nos contactáremos con los solicitantes con mas detalles. Cupos son limitados.

Contact Information

Name of Legal Guardian

First Name

Last Name

Phone

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Email

Verify Email

Patient's Information

Name of child

*

First Name

Last Name

Age of Child

Please note your child must be undergoing cleft surgical care in Central Texas to be eligible for a Cleft Care Kit

Child's Race/Ethnicity

*

Native American

Asian

Black/African American

Middle Eastern

Native Hawaiian/Pacific Islander

Hispanic/Latino

White

Other

Language(s) spoken in the home

Access to Services

Has your child been to an Austin Smiles local event before? If so, which event and what year?