Brochure Request Form for Speech-language Pathologists

Each brochure bundle includes 10 New to Apraxia brochures, 10 What is Childhood Apraxia of Speech Awareness cards, and digital resources.

Due to the rising cost of shipping, we charge a $5 shipping and handling fee for all orders.

Pay $5 to ship the kit

First Name *

Last Name *

Phone *

Email *

Are you requesting this kit to be sent to your business address?

Yes

No

What is the name of your business?

Address *

Address

City

State/Province

Zip/Postal

Country

How best would you describe your community?

Suburban

Rural

Metropolitan Area

These brochures are intended for speech-language pathologists. Are you an SLP? *

What setting do you currently work in? (If more than one, choose primary location) *

What is the name of your practice?

What ages of children do you treat? (check all that apply)

Birth to 3

Preschool 3-5

School age Kindergarten-5th grade

Grades 6-12

How many children with CAS or suspected CAS do you currently have on your caseload?

0-3

4-7

8-12

13+

Is this your first interaction with Apraxia Kids? *

Are you a member of the Apraxia Kids Speech-language Pathologist Directory?

Yes

No

How did you hear about this service? *

Would you like to make an additional donation to support our organization?

I would like to receive email communication from Apraxia Kids.

Credit Card

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