New Patient Information
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Child's Name/ Date of Birth
My child does not have many words
My child is difficult to understand when she/he speaks
My child has difficulty understanding what I tell him/her.
My child is having difficulty learning at school.
My child points or pulls to communicate and does not use many words
My child often cries and appears frustrated
My child will only eat certain foods and avoid all others
Has your child previously received speech-language services? If yes please, provide name, date and therapy informatiton
Form of Payment
Private Pay (insurance will not be directly billed)
Insurance (current insurance accepted Medicaid, Peach State, Amerigroup)
Out of Network Insurance provider (will need super bill to submit claim to the insurance company.)
Insurance Information: Name | ID Number
What type of services are you interested in?
In person (recommended for children 3 years and younger and significant delays)
Pediatrician's Name | Address
How did you hear about Shout SL Therapy?
Send me a copy of my responses.
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This form was created inside of Sherley Jackson.