Website Signup Form

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***Please note that we are restricted by physical distance for the areas we can serve with the size and locations of our therapy team.

If you have not done so already, please reference the maps provided on our website to understand whether we can see you in person.

If you are located outside of our treatment area, we are able to offer teletherapy.

To review our in-person treatment areas before proceeding, please follow this link:
https://inreachspeech.com/where-do-we-travel%3F
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How did you hear about us?* This field is required.Thank you SO much for taking the time to answer this question! It's really helpful for us to know where our referrals are coming from so that we can create deep connections in our community to advocate with unification for those we serve!
Please Select
Provider database from my insurance
Doctor or PCP
Teacher
Family member
Current client (word of mouth)
Another practice (word of mouth)
Another provider (word of mouth)
Social media
Internet search
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If you know the name of a specific person who referred you, enter it below.* This field is required.
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We do not accept MediCARE.* This field is required.We are OHP/Medicaid providers, but In Reach Therapy cannot accept new patients with any kind of Medicare coverage. We check each new sign up for Medicare coverage. If we find that you have Medicare coverage, we will help you locate the phone number on your card to find a provider who can assist you.
I understand.
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We do not offer collaboration or cotreatment with ABA services. We do not go to ABA centers to provide treatment.* This field is required.Please see our FAQs for more information on our ABA policy: https://inreachspeech.com/faqs
I understand
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To align with our model, the person seeking therapy must have at least two days per week available for treatment. This is to allow you the flexibility for make-ups as needed.* This field is required.
I understand
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We are unable to bill Aetna or Kaiser on your behalf; however, we can provide you with a superbill to submit to your Aetna or Kaiser plan for reimbursement of upfront costs out of pocket.* This field is required.If you would like to proceed with the knowledge that you will need to pay out of pocket and seek reimbursement from Aetna or Kaiser, please select YES. NOTE: If you have Aetna or Kaiser primary and OHP secondary, we will not be able to offer our services to you due to billing complexities with these plans. If you are unwilling to proceed having understood this requirement, please discontinue completing the remainder of this form.
I understand
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Is the client currently receiving care with In Reach Therapy?
Please Select
Please Select
Yes, the client is currently receiving treatment at In Reach Therapy.
No, the client is not currently receiving treatment at In Reach Therapy.
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Is the client a family member of a current In Reach client?
Please Select
Please Select
Yes, the client is a family member of a current In Reach client.
No, the client is not a family member of a current In Reach client.
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Name of parent or caregiver if applicable* This field is required.Type N/A if none
First Name
Last Name
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Full legal name of person who will receive therapy* This field is required.
First Name
Last Name
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Pronouns of the person who will receive therapy* This field is required.
Please Select
Please Select
She/her
He/Him
They/Them
Non-binary pronouns
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Email* This field is required.
example@example.com
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Phone Number* This field is required.PLEASE ENTER ONLY ONE PHONE NUMBER AND NO TEXT
Please enter a valid phone number.
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When is the best time to call you?* This field is required.Select all that apply.
Anytime
Morning (8am - 12pm)
Afternoon (12pm - 4pm)
Evening (4pm - 6pm)
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How do you prefer to be contacted?* This field is required.
Please Select
Please Select
Text (SMS)
Email
Phone call
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Primary Insurance or Self Pay?* This field is required.Select your insurance or "self pay" from the drop down. You will enter your insurance information in the next question.
Please Select
Please Select
Aetna or Kaiser (you understand that we do not bill these insurances and you are responsible for charges)
Self pay (out of pocket)
BlueCross BlueShield
Moda
Pacific Source
Providence
CareOregon
OHP
OUT OF NETWORK: Cigna
OUT OF NETWORK: First Health
OUT OF NETWORK: United Healthcare
OTHER
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Subscriber ID number or Patient ID number* This field is required.Typically the first long set of numbers on the front of your insurance card. Type N/A if self pay.
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Group number* This field is required.Listed as a second, shorter set of numbers typically under the subscriber ID on your card. Type N/A if self pay or if no group number is listed.
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Is the person seeking therapy covered by MediCAID (OHP)?* This field is required.
YESNO
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Subscriber Date of Birth* This field is required.Typically, if the insurance is through an employer, the subscriber is the employee. If the insurance is through the state, the subscriber is the person in need of therapy you named earlier. Type N/A if self pay.
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Does the person seeking therapy have secondary insurance coverage?* This field is required.
YESNO
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Select the secondary insurance plan below* This field is required.Select your insurance or "self pay" from the drop down. You will enter your insurance information in the next question.
Please Select
Please Select
NONE
Aetna or Kaiser (you understand that we will not bill these insurances)
BlueCross BlueShield
Moda
Pacific Source
Providence
CareOregon
OHP
OUT OF NETWORK: Cigna
OUT OF NETWORK: First Health
OUT OF NETWORK: United Healthcare
OTHER
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Subscriber ID number or Patient ID number* This field is required.Typically the first long set of numbers on the front of your insurance card. Type N/A if self pay.
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Person seeking therapy: Date of Birth* This field is required.
Date
Month
Day
Year
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What is the primary language spoken?* This field is required.If it is a language other than English, we will secure an interpreter for you. This will not affect your access to our services.
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Please list any current medical diagnoses* This field is required.
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ST, OT, or both?Notice that speech and occupational therapy have some overlap in their scopes of treatment. Take a moment to consider which areas the client needs help with and which discipline can help. It could be both!
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Select all areas of need that apply!* This field is required.
OT: Balance and coordination, hand-eye coordination
OT: Dressing, bathing, toileting, utensil use
OT: Sensory and emotional processing
BOTH OT and ST: Interacting with others and navigating daily routines
BOTH OT and ST: Feeding and Swallowing
BOTH OT and ST: Attention, thinking, and learning
ST: Saying speech sounds and being understood by others
ST: Using words, making sentences, language expansion
ST: Stuttering and cluttering
ST: Literacy and Reading
ST: AAC and Talking Software
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Based on your previous selections, notice if any areas could be addressed by BOTH speech-language and occupational therapy. Select the the statement that is the most accurate for the client's needs.* This field is required.
Please Select
Please Select
I selected areas that both disciplines could help with, but we only want SPEECH therapy at this time.
I selected areas that both disciplines could help with, but we only want OCCUPATIONAL therapy at this time.
The client is seeking BOTH speech therapy and occupational therapy.
The client is only seeking OCCUPATIONAL therapy at this time.
The client is only seeking SPEECH therapy at this time.
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Select all possible days available for ongoing treatment. You MUST choose at least two days.* This field is required.You will be asked for time of day in the next question
Open availability
Monday
Tuesday
Wednesday
Thursday
Friday
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After school spots are typically the most in-demand times for our clinicians. If you have flexibility for daytime, wait for one-on-one treatment could be reduced.* This field is required.
I understand
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Select all possible times of day for ongoing treatment* This field is required.
Open availability
8am - 10am
10am - 12pm
12pm - 2pm
2pm - 4pm
4pm - 6pm
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Are you interested in Teletherapy?* This field is required.AKA Virtual Therapy or Telehealth
Yes
No
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Does the patient use a communication device? Also known as a speech-generating device, AAC, or a "talker". If so, please give information below.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
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How familiar are you with neurodiversity-affirming approaches?* This field is required.This will help guide us during your consultation when you are matched with a clinician.
I am very familiar and have read books/listened to podcasts/subscribed to leading sites
I am pretty familiar and have heard some information about how it is different from traditional approaches
I am kind of familiar and have heard the word here and there
I do not know or have not heard of this type of approach
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Select all offerings of interest* This field is required.PLEASE NOTE: Some of the offerings below are in a development phase and not yet available to the public. By selecting offerings of interest, we can gauge community priorities which can guide focus for timelines in process development.
One on one treatment (in-person at home, school, in the community, or via telehealth)
Caregiver support groups
Community-based group treatment
Consultative services: brainstorming solutions for specific challenges
Community meetups
Education sessions
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Is there anything else you would like us to know?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
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What's next?* This field is required.1. You will be added to our waitlist, which is arranged in map-form due to our community-based model. 2. One of our office staff will call you to provide further details and to get any clarifications needed. 3. You will receive an occasional check-in email to which you can respond to make any changes to any information provided. 4. If you selected interest in service offerings in addition to one-on-one treatment, you will be contacted by a Lead clinician to get more information about your needs and interests, and to give info on what to expect for these services. 5. For one-on-one treatment: You will be notified via text when you are matched with a clinician. YOU MUST RESPOND TO THIS MESSAGE WITHIN 48 HOURS to claim your spot. If we do not hear from you, we will assume you are no longer in need of our services and we will remove your interest form from our waitlist.
YESNO
Should be Empty: