Appointment Request
Thank you for your interest! Please answer a few questions to help us get a sense of your family's needs before we connect with you to schedule your first appointment.
* Required
Email address
*
Your email
What is your child's name?
*
Your answer
What is your child's current age?
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Your answer
What is your child's date of birth?
Your answer
What is your name?
*
Your answer
What is your phone number?
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Your answer
What is your email address?
*
Your answer
What services are you seeking?
Evaluation
Therapy
I'm not sure
Other:
What areas are you concerned about? (check all that apply)
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My child isn't talking or has few words
My child seems behind kids his/her age
My child's speech is hard to understand
I can understand my child but some sounds are hard for him/her
My child has a hard time expressing him/herself with words
My child seems to be stuttering
My child has difficulty with feeding and/or swallowing
My child struggles with reading
My child struggles with writing
My child's teacher (or other professional) suggested we get an evaluation
My child's voice seems unusual (hoarse, strained, raspy, unusual pitch)
My child does not seem very interested in interacting/communicating with others
My child likes being with other kids but is having difficulty making friends and playing with others
I sometimes wonder if my child has trouble hearing me
My child doesn't always respond when others talk to him/her
My child has trouble following my directions or answering my questions
I'm concerned about how my child's voice sounds (ex: hoarse, nasal, scratchy, breathy)
I'm not sure
Other:
Required
Has your child had a speech/language evaluation?
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Yes
No
I'm not sure
(0ptional) What evaluations has your child had? (speech/language, OT, PT, developmental, neuropsych, psychoeducational)What were the results?
Your answer
Has your child had any previous speech/language therapy?
*
Yes
No
(Optional) Please share any pertinent information about your child's previous speech/language therapy?
Your answer
(Optional) Is there anything else you would like to add about your reason for seeking speech/language help?
Your answer
How many health insurance plans is your child covered under?
*
None
One
Two
I'm not sure
Which insurance plans cover your child?
*
Blue Cross PPO (including Anthem)
Blue Cross EPO
Blue Shield PPO
Blue Cross Blue Shield PPO
Health Net PPO
Kaiser Permanente
United Health Care
Aetna
Cigna
HMO - Brown & Toland
HMO - Hill Physicians
Medi-Cal
I'm not sure
Other:
Required
When would you like to get started?
*
As soon as possible
Summer
Flexible
Other:
Please describe your child's general availability (days and times they could attend sessions on a regular basis).
*
Your answer
How would you like to be contacted about next steps?
*
Phone
Email
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