Intake Form | Speech Zone NYC

First name

Last name

Phone

About your child

How old is your child?

When does thumb sucking typically happen?

Readiness & motivation

Has your child expressed any interest in stopping, even casually?

Yes — they've brought it up themselves

Sort of — they're open to it when we talk about it

Not yet — this is mostly our concern right now

They've tried to stop before but struggled

In your own words, how does your child feel about the idea of stopping?

Has anyone else encouraged your child to stop — dentist, teacher, family members?

Background & goals

Is there anything else you'd like the team to know before your first visit?