SCHEDULE A SPEECH THERAPY CONSULTATION

Please fill out the fields below to submit an inquiry or service request to us electronically. Your information will be reviewed and contact will be made within 24 hours to discuss services.

Schedule A Speech Consultation

Within 24 hours, we will review your information and get in contact to discuss how we can help.

* denotes a required field





Date Of Birth: *

Parent's Name: *








Address











Preferred Method of Contact:

Are you a recipient of the Family Empowerment Scholarship (formerly Gardiner) scholarship?*

Geographical Area: *




Diagnosis

Select your child's diagnosis or (if multiple) diagnosis.

Please list any relevant diagnoses? *

If no autism diagnosis, please list the relevant diagnoses:

If your child has been diagnosed with autism, has your child had a Comprehensive Diagnostic Evaluation completed?

If yes, does the Comprehensive Diagnostic Evaluation include an ADOS, CARS or other structured assessment?

If yes, please Provide the Name of the Provider and / or Their Practice That Conducted the Evaluation:

If yes, in What Year Was the Evaluation Completed? (Approximate Is OK.)

Who Is Your Insurance Carrier? *

If your insurer is not listed, don't worry: we can still help. Please let us know of your carrier in the comments.

How did you hear about us? *

Additional Comments: