Child's Name
*
First Name
Last Name
Age
*
Parent's Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Parent's E-mail Address:
*
Which service(s) would you like to pursue with us?
*
An in-office consultation
An evaluation only
Treatment only (I already have and evaluation less than 6 months old)
An evaluation and ongoing treatment
Identify the primary area(s) of concern:
Language (how information is understood and/or expressed)
Articulation (way words are said)
Social-Pragmatics (interaction with others)
Fluency (smoothness of speech)
Cognitive (learning, memory, problem solving
Autism Spectrum Disorder
Feeding Aversion (chooses to eat specific foods only)
Developmental Delay (untimely achievement of milestones)
Other
Any additional information you'd like to share?
*
Will you be using insurance benefits?
*
Yes
No
Which insurance?
*
This information helps in determining the length of time it will take to complete the authorization process.
Preferred day/time for meeting:
Tuesday AM
Wednesday AM
Thursday AM
Tuesday PM
Wednesday PM
Thursday PM
How did you hear about us?
*
This form was completed by:
Parent/Caregiver
Atlanta Speech Therapy Employee
I understand Atlanta Speech Therapy will attempt to contact me by phone and e-mail regarding availability. I must respond and complete the requested online paperwork by the date and time specified or I risk being removed from the waiting list.
Yes
No
Submit
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