Patient's Legal Name* Patient's Date of Birth* Phone* Email* Preferred Time*MorningAfternoonEveningPlease indicate concerns* Feeding/Swallowing Language Articulation Stuttering/Disfluency Social Skills Aphasia Please give us more details*Insurance Card* Drop files here or Select files Accepted file types: pdf, jpg, png, Max. file size: 256 MB, Max. files: 2. Please upload front & back of insurance cardPlease use this form for general information purposes only. DO NOT send personal health information through this form. Specific patient care must be addressed during your appointment.Please complete the following form to request an appointment. Please also note that availability will vary depending on your request. Your appointment will be confirmed by phone by a member of our staff. Thank you!Coverage Warning* I have read the statement below.Upon receipt we will verify insurance prior to the initial session. Please note, if we do not accept your insurance, services are eligible via private pay, and/or Department of Education vouchers.CommentsThis field is for validation purposes and should be left unchanged.
