Gold Speech Intake Form

Gold Speech Intake Form

Name of person to receive services
Or put n/a

New intakes are on hold until further notice

Not accepting new names to waitlist.
We thank you for visiting.
Intake form will be reactivated upon signing an additional team member.

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! ​

Coverage areas