Request for free phone consultation (caregiver version)

Please complete the following questionnaire in order to receive a free phone consultation. We will call you back within one business day to discuss your concerns and to see whether you'd like to set up an appointment for an initial evaluation/consultation. 

 

This questionnaire is for potential new patients only. Current patients should not submit health information through this website. Please contact us via phone or email if you would like to discuss any health matters further.

New patient's name *
New patient's name
Patient's Date of Birth *
Patient's Date of Birth
Phone 1 *
Phone 1
Phone 2 (optional)
Phone 2 (optional)
Address *
Address
Examples: "Lives alone," "She has a 24-hour home health aide," "He lives with his adult son," "She lives with her mother," etc.
Service
Please choose the service(s) that you are interested in:
For example, "My mother wants to be understood by her friends and family," "I want my brother's voice to be clearer," "We want to bring my parent to eat a regular meal at a restaurant."
Have they experienced any of the following?
In the last 12 months, have they seen any of the following professionals?
Have they ever received speech (or swallowing) therapy before? *
If you wish, you can choose a preferred time of day for the appointment. Note that this is not a guarantee of the therapist's availability. We will call/email to confirm an appointment time that works for you and the patient.
Type of visit *
Choose what you/the patient would like to do for the first visit. You can always change your mind when booking another appointment in the future.
Insurance type
PLEASE NOTE: We do not currently accept insurance. We are in the process of enrollment in Medicare. Upon request, we do provide documentation if you would like to submit to your insurance company for reimbursement. Your insurance company information helps us to determine what information will be needed in this documentation.

PLEASE NOTE: By pressing Submit, you are agreeing to transmit health information electronically. All paper and electronic information for current patients is transmitted, and is stored by our office, in a manner compliant with HIPAA, however we cannot guarantee the security of information transmitted by third-party servers for current non-patients.