AIS Interest form
Please fill out this form if you are interested in working with AIS in speech therapy.
I am a current or past client of AIS
I am a new client of AIS
Current or Previous Clients:
You have indicated you're a current or previous client. Please contact your therapist or the AIS office at admin@stutteringtreatment.org to get an invitation to apply for Financial Assistance!
Client Details
First Name
Last Name
City
State/Province
Country
Mobile Phone
Contact Email
Client Date of Birth
Referred by:
Please select...
AIS Website
Referred by Friend/Family (Please specify)
Facebook
Internet Search
Partner Referral (Please specify)
School
Newspaper
Other
Referred by Other:
Please describe your concerns and goals for speech therapy:
I would like to apply for financial assistance through AIS to help pay for my treatments.
Yes
No
Contact Information