Request for free phone consultation (pediatric 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.

Child's name *
Child's name
Child's Date of Birth *
Child's Date of Birth
Phone 1 *
Phone 1
E.g., Home, Mom work, Dad cell, Grandma cell
Phone 2 (optional)
Phone 2 (optional)
E.g., Home, Mom work, Dad cell, Grandma cell
What is the best way to contact you?
Child's Address #1 *
Child's Address #1
Child/Caregiver Address #2 (optional)
Child/Caregiver Address #2 (optional)
Preferred address for mail correspondence (if more than one address)
Examples: "Lives with mother and sister", "Father, Mother, brother, and grandmother", "With Mother/Stepparent/brother 2 days per week, and Father/Stepmother's house 3 days per week"
Who will bring the child to the office for the first visit? *
Service
Please choose the service(s) that you are interested in:
For example, "I can't understand what my child says", "Our child can't drink from a straw and only eats soft/pureed foods", "My son stutters when he is nervous", "My daughter can't say R sounds"
Has the child experienced any of the following?
In the last 12 months, have they seen any of the following professionals?
Have they ever received speech, feeding, 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 child.
Type of visit *
Choose what you 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 currently ONLY accept Medicare in-network. Upon request, we do provide documentation if you would like to submit to your insurance company for reimbursement. This only works if you have "out-of-network" Speech Therapy benefits--you can call your insurance company to check. 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. This is an informal request for information from non-patients. All paper and electronic information for current patients 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.

If you are a current patient, please DO NOT use this form to transmit information. Please call 347-676-0332 to arrange a phone call with your therapist.