CLINIC, HOME, AND TELEHEALTH

Speech Therapy

Services to support your child's developmental needs

For New Patients

Your Name

Relationship to Child

Email Address

Phone Number

Insurance Type

Child's Name

Child's Date of Birth

Address Line 1 (Street Address)

Address Line 2 (City, State)

Diagnosis

Pediatrician's Name

Insurance ID

Name of School (if in school)

Pediatrician's Phone Number

Services received in school:

Reason for Requesting Services

Other Private Services Received

ABA Therapy

Occupational Therapy

Physical Therapy

Other

Current Medications & Dosage (if applicable)

Previous Experience with Speech Therapy (if any):

Availability for Speech Services:

Preferred Service Location

In-person

Telehealth

Do you have a speech referral from your child's doctor?

Yes

Is there anything else you'd like to share before submitting your request?

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!