Pediatric Therapy Waitlist
We currently provide Speech and Occupational Therapies. Physical Therapy is a service we plan to offer in the future.

Wait time depends on the services needed. Expect to wait 3-5 business days to receive a call from our office. 

Please complete the form to add you or your child to our waitlist. Please note, we are currently only accepting clients for speech delay, apraxia of speech, sound disorder, fluency, language or pragmatic therapy. 

You will need a referral from your or your child's primary care provider (MD or NP) before services can begin. Fax referrals to 678-868-2843 AS WELL AS completing this form. If you have MEDICAID, please request a Certificate of Medical Necessity from your pediatrician along with the referral.
Email *
Name of Person Completing Form *
Relation to Client *
Client's First Name *
Client's Last Name *
Client's DOB *
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Name of Client's Primary Care Provider & Clinic *
PCP's Primary Phone Number *
Has your speech and/or OT referral been faxed to our office? You must have a well-child visit with your doctor every 6 months.  *
What location in MS are you interested in?
Clear selection
What type of service(s) are you interested in? *
Required
Primary Insurance (If your insurance is not listed, we do not accept it, you may select self-pay, which is $350 for each evaluation, $65/session for speech, and $75 for OT).  *
What's your primary insurance Member ID #? (Write none if you do not have primary insurance) *
Secondary Insurance (If your insurance is not listed, we do not accept it) *
What's your secondary insurance Member ID #? (Write none if you do not have secondary insurance) *
Are you willing to do self-pay until we are in-network with your insurance? (Rate: $65 for Speech, $75 for 30 minute OT/$90 for 45 minute OT, Initial Evaluations $350 each) *
Parent's/Client's Phone Number *
Parent's/Client's Email *
Is the client currently receiving Speech/OT services somewhere else?  *
If currently receiving services, where?
What was your last date of service?
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If you are currently receiving services elsewhere, you understand that you will have to sign a transfer of care form prior to services with IPS. *
Any additional comments/questions:
A copy of your responses will be emailed to .
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