2026 Registration for Individual Speech and Language Treatment
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Email *
Last Name, First Name of Client *
Client's Date of Birth *
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DD
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Client's Primary Home Address: Street, City, Zip *
Father's Last Name, First Name
Father's Email
Father's Cell Phone Number
Mother's Last Name, First Name
Mother's Email *
Mother's Cell Phone
Insurance Carrier *
Insurance Member ID # *
Group ID#
Insurance Policy Holder's Name
Insurance Policy Holder's Date of Birth
PCP or Pediatrician's Name, address, phone
Has this client received speech therapy previously?
Please describe your current concerns:
Any additional questions or information you would like to ask/share?
How would you like to receive services?
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Would you be interested in a Parent Education Class to learn how to help your child at home?
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How did you hear about A Sound Beginning, LLC?
Do you give permission for A Sound Beginning, LLC to direct bill your insurance company and be reimbursed directly for any medical services performed?
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Do you understand that any financial responsibility you have for copays, deductibles, and balances not covered by insurance will be billed directly to the policy holder/parent/guardian? All clients must agree to having an active credit card saved on their account to cover patient responsibilities and/or no show fees. Choosing no will result in not receiving services at A Sound Beginning.
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Do you understand that a $45 fee will be assessed and must be paid for any missed or late cancellation (less than 48 hours notice) appointments before the next session can occur?  If this fee is not paid, sessions at ASB will be suspended. Therapy timeslot will not be saved during this suspension. Choosing no will result in not receiving services at A Sound Beginning.
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