Literacy Boost® Referral form...

Childs Name:
Date of Birth:
Age:
School:
Teacher
Current Year Level:
Parents Name:
Address:
Phone:
Email:
Literacy Concerns:

PRIVACY STATEMENT: GIANT LEAPS Speech Company collects personal information about their clients to support their assessment and intervention and to ensure that effective services are provided. Information may be shared with other specialists and professional agencies necessary for the provision of our effective services. It is not compulsory for you to provide any personal information but we may not be able to provide the most effective services for you if you do not. You have the right to request access to, and correction of personal information held by GIANT LEAPS Speech Company at any time.

Privacy Permission:

PLEASE READ OUR COMPREHENSIVE TERMS AND CONDITIONS HERE

Agreement: