• Intake Form

Gold Speech does not accept insurance. We will provide a monthly statement which you can submit to your insurance for reimbursement. Dawn Gold and her Associates are considered out-of-network and are not affiliated with any insurance companies.

Your personal information will be kept strictly confidential and will only be viewed by Gold Speech for the purposes of scheduling speech therapy services. By completing this form, you enable Gold Speech to initiate a conversation with you about scheduling services for you or your child. Because we offer home-based speech therapy, it is necessary to know the address in advance in order to match geographical coverage areas with scheduling availability. Thank you! ​

Intake Form

Complete home mailing address including city and zip code:*
Location where services are to be delivered, if different from home address:
Client's first name:*
Client's last name:*
Client's date of birth:*
Grade and name of school, if applicable:
Do you have pets in your home?:*
CatDogOtherNo pets
Has an evaluation been done to address the concern(s)? Please check all that apply:*
YesNoUnsureAssessment is in progressTreatment plan already establishedMy child has an IEP at schoolMy child has an IFSP
Please list any relevant diagnoses:
Please tell us how we can help you:*
Will you need a statement to submit to insurance or work place for reimbursement of services? *
Referral source: *
Please list all available days and times for sessions. The more possibilities you list, the greater the likelihood we can help you. Note that sessions for children are 45 minutes long.*
You may upload relevant files such as previous evaluations, progress reports, IEPs, IFSPs, audiology results, etc.

2nd file if applicable