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1CONTACT INFORMATION

2AVAILABILITY TO BE SEEN

3CLIENT INFORMATION

4PET INFORMATION

5PREVIOUS EVALUATIONS

6NATURE OF THE PROBLEM

7INSURANCE REIMBURSEMENT FROM YOUR PPO

Your Name *

First

Last

Email *

Mobile Phone *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Referral Source *

Select the type of service you desire: *

In-person services 8:00 AM - 2:30 PM weekdays
In-person services after 3:00 PM weekdays
Telehealth services

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

Yes
Unsure, I will ask
No
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 *

Client's Name *

First

Last

Name of person to receive services

Client's Date of Birth *

Name of school and grade in 2023-24, if applicable *

Or put n/a

Languages spoken in the home *

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

Other

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

Please list any relevant diagnoses

Areas of concern - check all that apply *

speech is unintelligible
speech has errors on one or more specific sounds
delayed or disordered expressive language
difficulty understanding directions or conversations
delayed or rigid play skills
difficulty socializing with others
stuttering
feeding and/or swallowing
speech has unusual rhythm and/or sounds monotone
my foreign accent is difficult to understand
voice quality and/or resonance

Please elaborate on your child's current communication, problem areas and how we can help you. If you are an adult seeking services for yourself, explain specifically what you are struggling with and what your goals are. *

Are there any challenging behaviors we should be aware of?

very short attention span
highly active - tends to run away, hide, climb on furniture, etc.
very hard to engage even with a familiar adult
has used significant physical behavior toward others within the last 6 months: biting, scratching, shoving, hitting, pulling hair, etc
other

Other

Will you need a statement to submit to insurance for reimbursement of services? *

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

Other type of insurance

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

Yes
No
Maybe
N/A

Captcha *

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