Please fill out the inquiry form below to be added to the Speech Language Pathology Feeding Waitlist. If you do not complete this form you will not be added to the waitlist. Name * First Name Last Name Child's Name * First Name Last Name Child's Date of Birth or Due Date if inquiring pre-birth * MM DD YYYY Phone * (###) ### #### Email * Please explain your concerns and reason(s) for seeking assessment: * Who would you prefer to see for your child's assessment? * Karlie Hudon Nikki Dooley Either Karlie or Nikki Who recommended you see us? * Has your child undergone a tongue and/or lip tie release? * Yes No Does your child have any medical diagnoses that may impact their feeding? * Yes No Thank you for your inquiry! You have been added to the waitlist.****** IMPORTANT NOTICE ******WAITLIST IS CURRENTLY APPROXIMATELY 4-8 WEEKSYOU WILL RECEIVE A PHONE CALL FROM THE VILLAGE YXE WHEN AN APPOINTMENT COMES AVAILABLE WHICH MAY NOT BE UNTIL THE WEEK BEFORE THE AVAILABLE APPOINTMENT. PRIORITY IS FOR INFANTS UNDER 6 MONTHS OF AGE. KARLIE SEES CHILDREN 0-12 YEARS OF AGE AND NIKKI SEES INFANTS 0-18 MONTHS OLD. SHOULD CANCELLATIONS ARISE, CLIENTS WILL BE CONTACTED BASED ON URGENCY. IF YOU ARE AN ADULT OR HAVE A CHILD OVER THE AGE OF 5 LOOKING FOR MYOFUNCTIONAL THERAPY, PLEASE SCHEDULE IN WITH NICOLE ACKERMAN THROUGH THE VILLAGE YXE BOOK NOW LINK.IF YOU ARE INQUIRING FOR YOUR PICKY EATER OR OLDER CHILD EXPERIENCING FEEDING ISSUES PLEASE BOOK WITH OUR REGISTERED DIETITIAN MELISSA DIETRICH THROUGH THE BOOK NOW LINK.