Dynamic Therapy Initial Patient Forms

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We are so excited you are interested in speech and augmentative communication services at Dynamic Therapy! Please take a moment to begin completing our initial information forms and we will be happy to get you started!

PLEASE CLICK "NEXT" AT THE END OF EACH PAGE. WHEN YOU SEE "SUBMIT" YOU ARE ALL DONE!

Email *

Name of Patient *

Patient's Date of Birth *

YYYY

Parent/Guardian Name (if applicable)

Best phone number to reach you *

Gender (patient) *

Female

Male

Place of Service Requested

Office/Clinic Visits Only

Telehealth/Telepractice Online Appointments Only

Primarily Telehealth supplemented by in office visits as needed

Primarily Office/Clinic visits supplemented by telehealth as needed

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Type of Service Requested *

Speech/Language Therapy

Speech Generating Device (AAC) Therapy

Speech/Language Evaluation

Speech Generating Device (AAC) Evaluation

Unsure

Other:

Required

Please list your preferences as to days and times you are available for therapy. Also, please list as many options as possible....(the more open your availability, the sooner we may be able to get you scheduled) *

Payment Type *

Private Private Pay, Insurance or Medicaid (Deeming Waiver, NOW/COMP or SSI Medicaid)

Medicaid CMO (Wellcare, Amerigroup, Peach Care, Peach State)

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