Rutgers SLP Clinic Interest Form

Welcome to the Rutgers University Speech-Language Pathology (RU-SLP) Clinic!

Thank you for your interest in our clinic. We offer free speech and language testing and therapy for people of all ages and needs. You do not need insurance or legal documents to receive services with us.
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Who We Are

Our services are provided by graduate students working toward their Master’s degree in Speech-Language Pathology. They are closely supervised by licensed and certified speech-language pathologists.

What We Help With
We support a wide range of needs, including:

Speech and language disorders

Voice disorders

Stuttering

Autism and social communication challenges

Feeding and swallowing difficulties Executive functioning issues

Aphasia

Motor speech disorders

Clinic Schedule

In-person and virtual visits are scheduled during the months below:

Fall: September – November
Spring: January – April
Summer: Limited availability

Getting Started
All new clients begin with an initial evaluation (90–120 minutes). After that, we may recommend therapy based on your needs and availability.

Therapy sessions are 50 minutes long and are held on Mondays and Wednesdays.

Language Support

We offer services in:

English Spanish American Sign Language (ASL) Interpretation for other languages is also available.

Ready to Begin?

Please fill out the form below, and a team member will contact you within one week.
Full Name of Client*

First NameLast Name
Client Pronoun(s)
Ex: she/her/hers, he/him/his, and they/them/theirs
Client's Date of Birth*

MonthDayYear
Contact Number*
Please enter a valid phone number.
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you completing this form for yourself or for someone else?*

I am completing this form for myselfI am completing this form on behalf of someone else
If for someone else, please share your name and your relationship to the client:
If completing for someone else, please share your name and your relationship to the client:

First and Last NameRelationship
Reason for Seeking Services
What are your current concerns or reasons for contacting the RU-SLP Clinic? (Select all that apply)

Difficulty being understood when speakingTrouble understanding what others sayProblems expressing thoughts clearlyStuttering or speech that feels “stuck”Voice concerns (hoarseness, pitch, vocal fatigue)Gender affirming voice and communicationChallenges with memory, attention, or thinkingSocial communication (e.g., knowing what to say, reading social cues)Difficulty chewing or swallowingFeeding concerns (e.g., picky eating, food refusal)Delays in language developmentOther (please describe below)
Other Reason for Seeking Services
Please provide more details for what was selected above
How did you hear about the Rutgers SLP Clinic? (Select one)

Physician or healthcare providerSchool or educatorFamily member or friendInternetOther
Name of person/place that referred you
Are you interested in an Evaluation, Treatment, or joining one of our Groups? Note: If you are interested in treatment, an evaluation at the RU-SLP Clinic is required as a first step.*

Evaluation ONLYEvaluation and TreatmentGroup
Select Group(s)

Gender Affirming Voice and Communication (ENGLISH)Parkinson’s Voice Group (ENGLISH)Clubhouse Group for Autistic Adults (ENGLISH)Job Readiness and Life Skills for Teens and Young Adults (ENGLISH)Voice Group (ENGLISH/SPANISH)Brain Injury Caregiver and Survivors with BIANJ (SPANISH)
How would you prefer for us to contact you about scheduling? (Select all that apply)

EmailPhone callText messageOther (please specify)
What language should communication be conducted in? *

English onlySpanish onlyEnglish and/or SpanishOther
What language(s) are spoken at home (please list any and all languages)?
Do you have reliable transportation to attend an in-person evaluation at our clinic?

YesNoSometimes
If you answered Yes or Sometimes to the question above, please provide more information here:
Do you have any accessibility or mobility needs we should be aware of (e.g., elevator access, wheelchair use, sensory accommodations)? *

YesNo
Please describe your Accessibility needs:
Do you have a preference for how your sessions are conducted?

In-personVirtual (tele-health)No preference
Have you received speech-language therapy services in the past?

YesNoNot Sure
If yes, please briefly describe where, when, and what the focus of therapy was:
Do you have any other questions or information that you would like to share?"
Should be Empty:

Welcome to the Rutgers University Speech-Language Pathology (RU-SLP) Clinic!

Reason for Seeking Services