Test Page – Gold Speech, Inc.

CONTACT INFORMATION - Step 1 of 7

Name *

First

Last

Email *

Phone *

Choose One *

Mobile
Work
House Line

Address *

Address Line 1

City

State / Province / Region

Postal Code

Referral Source *

Select the type of service you desire: *

Waitlist for in-person services 8:00 AM - 2:30 PM
Waitlist for in-person services after 3:00 PM (several months)
Virtual telehealth services weekdays or Sundays

Is it a possibility to see your child at preschool / daycare / private school? *

Yes
Unsure, I will ask
No
N/A

Client's Name *

First

Last

Client's Date of Birth *

Grade in 2022-23 and name of school, if applicable *

Do you have pets in your home? *

Cat
Dog
Other
No Pets

Has an evaluation been done by a speech pathologist to address the concern(s)? Please check all that apply

Yes
No
Unsure
Assessment is in progress
My child has an IEP at school
My child has an IFSP

Have other specialists already evaluated your child? Please check all that apply

Behavioral/Developmental Pediatrician
Psychologist
Occupational Therapist
ENT (Ear, Nose, and Throat Specialist)
Other

You may upload relevant files such as previous evaluations, progress reports, IEPs, IFSPs, audiology results, etc.

Click or drag files to this area to upload. You can upload up to 2 files.

Please list any relevant diagnoses:

Please tell us how we can help you *

Are you interested in a social language group for four to six year-olds? *

What insurance carrier provides your medical coverage? This question is informational only to help us determine appropriate codes to include on your superbill. We do not handle claim submission or phone calls to your insurance company. *

Anthem Blue Cross
Blue Shield of California
United Healthcare Primera of United Healthcare
Aetna Meritain of Aetna
Cigna
Health Net of California
Kaiser (not reimbursable)
Other

Would you potentially be interested in a social language group for four to six year-olds? *

Yes
No
Maybe
N/A

Please list ALL available days and times. The more possibilities you list, the greater the likelihood we can help you. Note that individual sessions are generally 45 minutes long *

Captcha *

To be considered for services, please complete an intake form for your child or yourself.

CONNECT WITH US

Call: (650) 669-8539

Serving homes in Palo Alto, Los Altos, Mountain View, Sunnyvale, Santa Clara and parts of Cupertino and San Jose, California