Schedule an Evaluation

If your child is having trouble with hearing, speech, dyslexia, or other learning disorders, we would love to schedule an evaluation. Please complete the following electronic intake form, and Magnolia Speech School will reach out to you with options for an evaluation.

Evaluation Intake Form

Questionnaire to provide information to evaluate an individual's initial assessment.

Child's Name*
First Middle Last
Child's Birthdate*
Child's Age and Gender*
Parent's Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Referred By
Current school or daycare
Primary Concerns*
Previous testing (S/L, Hearing, Educational, etc.)
Has your child received or is your child currently receiving any therapies?*
IEP*
Eligibility Ruling*
Additional information regarding Eligibility Ruling (if selected yes.)
Medical Diagnosis*
Additional information regarding Medical Diagnosis (if selected yes.)
Please provide any additional information.

Payment is required at the time of service. For more information, fees, or to schedule an evaluation for your child, please Magnolia Speech School’s Admissions Coordinator Melissa Newman at 601-914-9415 or by emailing her at melissa.newman@magnoliaspeechschool.org.

Magnolia Speech School

Schedule an Evaluation

Schedule an Evaluation

Evaluation Intake Form

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