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Phone: 205-582-7717
Email:
hello@saltandlight-slp.com
Location: Vestavia Hills, AL
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Thumbs Out Readiness Form
Child's name
*
Child's Birthday
*
Month
Day
Year
1. What habit are you seeking support for?
*
Thumb sucking
Finger sucking
Tongue habit
Other (briefly describe)
Other response
2. How long has this habit been present?
*
Less than 1 year
1-3 years
3+ years
3. Has your child expressed a desire or willingness to stop this habit?
*
Yes, they are motivated to quit
Somewhat, but unsure
I'm not sure they are ready
4. Have you attempted habit elimination in the past?
*
No
Yes, briefly describe what was tried below.
Short answer
5. Are you able to support daily expectations at home during a short-term program?
*
Yes
Possibly, but would like more information.
No
6. What is your primary goal in seeking this program?
*
7. I understand this is a private pay program and requires a 60 minute evaluation prior to enrollment.
*
Yes
Parent Name:
*
Phone
*
Email
*
Submit
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