Client Inquiry for Social Butterfly Inc. Speech & Language Services

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Please fill out this form in its entirety to get on our waitlist! AS OF 02/1/23 we have a waitlist for ALL appointments!

Email *

Communication concern (choose all that apply): *

Autism

Gestalt language processor

Stuttering

AAC (Augmentative and Alternative Communication)

Expressive and Receptive Language

Speech sounds or articulation

Non speaking or minimally speaking

Social Communication

Other:

Required

Your Name: *

Child's name (if child is the client): *

Child's date of birth: *

YYYY

Best Phone Number *

Best email address *

City and State *

Which service are you interested in *

In person in our Westmont location

In person in our Naperville location

Teletherapy appointment

It doesn't matter- will take any location

It doesn't matter- will take any location OR teletherapy

Gestalt Language Consultation

Required

Availability (check all that apply) *

Daytime (8-3pm)

Afternoons (3-7pm). After school appointments have a much longer waitlist.

I'd be open taking my child out of school early if a daytime appointment opens up.

Other:

Required

Has your child (or you) had a current speech-language evaluation in the past six months to one year? *

yes

What are your communication goals and why did you seek out services at Social Butterfly Inc? *

How did you hear about us? *

What are your child's strengths and interests? *

List any prior services (school and/or private clinic) *

We only accept out of pocket pay for services, but can provide you with a monthly superbill if you would like to submit for out of network with your own insurance.

Services are provided at the following fee schedule:

$300 Speech-Language Assessment with formal report and treatment plan (45-60 minutes)

$200 Informal Speech-Language Assessment without formal report, JUST treatment plan (30-45 minutes)

$166 60 minute therapy session (55 minute session, 5 minute notes/parent contact)

$125 45 minute therapy session (40 minute session, 5 minute notes/ parent contact)

$83 30 minute therapy session (25 minute session, 5 minute notes/parent contact)

$125/hr attendance at IEP meetings and school observations

$125/hr consultations with providers or parents

I understand this and I will be paying out of pocket

Required

Please check the boxes below to show us you understand our process! *

I am aware you have a waiting list for all speech-language appointments

I am aware that I will be contacted via email with ANY openings that match my selected availability

I am aware that I will have the opportunity to speak with a speech-language pathologist IF and WHEN an appointment becomes available

I am aware that I may be on the waitlist for as short as a day or as long as several months.

Required

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

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