Speech Therapy Waitlist

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Wait time depends on the speech 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 *

YYYY

Name of Client's Primary Care Provider & Clinic *

PCP's Primary Phone Number *

Has your speech referral been faxed to our office? You must have a well-child visit with your doctor every 6 months. *

Yes

Client will have a speech referral sent to Irby Psychological Services fax: 678-868-2843

What location in MS are you interested in?

Southaven

Clarksdale

Cleveland

Clear selection

What type of service/location are you interested in? (Select your primary concern) *

Articulation -- how words are said/sound

Language -- vocabulary, how many words

Primary Insurance (If your insurance is not listed, we do not accept it, you may select self-pay, which is $65/session). *

Aetna

United Healthcare/UMR/GEHA (Commercial)

UHC Medicaid/MS CAN (please remind your pediatrician to fax a Certificate of Medical Necessity to us at 678-868-2843)

Magnolia Medicaid (please remind your pediatrician to fax a Certificate of Medical Necessity to us at 678-868-2843)

MS Medicaid (straight) (please remind your pediatrician to fax a Certificate of Medical Necessity to us at 678-868-2843)

Ambetter Marketplace

BCBS (Note: coverage is dependent on individual policy)

Self-pay

Cigna

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) *

None

UHC Medicaid/MS CAN/MS CHIP (please remind your pediatrician to fax a Certificate of Medical Necessity to us at 678-868-2843)

Magnolia Medicaid (please remind your pediatrician to fax a Certificate of Medical Necessity to us at 678-868-2843)

MS Medicaid (straight) (please remind your pediatrician to fax a Certificate of Medical Necessity to us at 678-868-2843)

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: $65/30 minute session, $80/45 minute session; Initial assessments $250 for comprehensive assessment and $150 for infant until 12 months assessments). *

Yes

Maybe

Parent's/Client's Phone Number *

Parent's/Client's Email *

Is the client currently receiving Speech services somewhere else? *

Yes

If currently receiving speech, where?

What was your last date of service for speech?

YYYY

If you are currently receiving speech elsewhere, you understand that you will have to sign a transfer of care form prior to services with IPS. *

Yes

Any additional comments/questions:

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of irbypsychservices.net. Report Abuse

Forms