Griffin Speech, Chartered: Provider Referral Network Application
Griffin Speech, Chartered maintains high standards regarding referring our patients to other providers. If your practice can meet those standards, we would love to add you to our referral list. Complete this 5-question application so that we can learn more about you and determine if your practice is a good fit for our clientele.
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Email *
Provider or Facility Name:
Provider or Facility phone number:
Facility Website
Facility Address (including city and state)
1. Provider Type (check all that apply) *
Required
2. Does your practice have an in-house speech-language pathologist?
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3. Are you familiar with the benefits of coordinating your patients' care with a speech-language pathologist?
Clear selection
4. What are some of the disorders that you are interested in consulting with a speech-language pathologist regarding?
5. What is your care philosophy?
A copy of your responses will be emailed to the address you provided.
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