Dynamic Therapy Initial Patient Forms
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!
Name of Patient
Date of Birth
Parent/Guardian Name (if applicable)
Best phone number to reach you
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
Type of Service Requested
Speech Generating Device (AAC) Therapy
Speech Generating Device (AAC) Evaluation
Preferred Days/Times for Weekly Sessions (if needed)
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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This form was created inside of Dynamic Therapy Associates, Inc..