PEERS® Clinic Interest List

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If you would like to join one of our PEERS® Clinics, please complete the form below. We only have 10 spots available for each clinic. Participants will be registered in the order in which their registration is completed.

The clinic is 16 weeks. The cost is $250 per week which includes the rate for the client and the social coach. For more information please visit our website: www.SavvySpeechTherapy.com

Email *

Have you requested your referral to your insurance company? *

Yes

Have you received a referral from your insurance company? If yes, please email the referral from your PCP to info@savvyspeechtherapy.com

Yes. I will email the referral to info@savvyspeechtherapy.com

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Client's Name *

Child's Age *

Client's Date of Birth *

YYYY

Social Coach or Parent Name *

Phone Number *

Home Address *

Email address *

Choose your preferred PEERS® Clinic

PEERS® Clinic for Preschoolers

PEERS® Clinic for Adolescents

PEERS® Clinic for Young Adults

PEERS® Clinic for Pre-teens

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Type of Payment *

Private Pay (Cash, Credit Card)

IEHP (e..g., MediCal)

PHN

United Health Care

Superbill- client remits payment during the time of service and then submits the paid invoice to insurance for reimbursment (Out of Network Option)

Single Service Agreement- Client works with insurance company to set up SSA with Savvy Speech, Inc (Out of Network Option)

Self Determination Funds

Other:

If you do not see your insurance listed, please list your insurance company *

Please list your general question about the PEERS® Clinics *

Send me a copy of my responses.

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