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a holistic approach for speech, voice, language, and swallowing

Request for free phone consultation

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. 

Are you filling out this form for another person? Please fill out the caregiver version by clicking here. 

Name *
Name
Date of Birth *
Date of Birth
Phone 1 *
Phone 1
Phone 2 (optional)
Phone 2 (optional)
Address *
Address
Service
Please choose the service(s) that you are interested in:
For example, "I want to be understood by my friends and family," "I want my voice to be clearer," "I want to sound more feminine," or "I want to be able to eat a regular meal at a restaurant."
Have you experienced any of the following?
In the last 12 months, have you seen any of the following professionals?
Have you ever received speech (or swallowing) therapy before? *
If you wish, you can choose which time of day you prefer. Note that this is not a guarantee of the therapist's availability. We will call/email you to confirm an appointment time that works for you.
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: The only insurance we currently accept is 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.