TSCC Therapy Request Form-Columbus
Welcome to the TSCC Therapy Request Form page. Please take a moment to answer the questions below in order to help us better serve you.
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Email *
We're excited to support your little one! Answer the questions below to help us prepare for your initial phone call with a member from our TSCC team!
Today's Date *
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Patient First Name *
Patient Last Name *
Patient Age *
Patient DOB *
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Parent/Legal Guardian Name (if child under 18) *
Home Address *
City *
State *
Zip Code *
Contact Number

By providing a telephone number and submitting this form you are consenting to be contacted by SMS text message. Message & data rates may apply.

No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All other categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties

Enter Contact Number Below
 *
If you wish to not receive SMS communication regarding your interest in our services, please indicate below by selecting "opt-out."
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Speech/Language Concerns *
What type of speech therapy service are you interested in? *
Currently Receiving Private or School-Base Speech Therapy Services? *
If your health insurance plan is not listed below, this means we are out-of-network with your plan. You are eligible for our TSCC Direct Speech Therapy Membership Plan. Learn more about this private pay membership plan on our website.
Select TSCC Direct Speech Therapy Membership (10.) below if you are interested.
Select your funding source? We are not accepting new Medicaid or Medicaid Managed Care members at this time.  *
Receiving other therapy services? *
How did you hear about TSCC? *
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