Website Signup Form

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***All forms of medical care are struggling with staffing shortages across the nation, and we are no exception. Although we are working very hard to staff our clinical team with providers who are vetted and appropriate for the model we provide, our ability to meet needs in certain areas is reduced.

At this time, the area of longest wait is the Beaverton area and Tigard/Tualatin.

***Please note that we are restricted by physical distance for the areas we can serve with the size and location 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 treatment areas before proceeding, please follow the link below:
https://inreachspeech.com/treatment-areas
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Does the patient have MediCARE?We ARE Medicaid (OHP) providers, but we do NOT accept Medicare.
YESNO
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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.Would you still like to proceed with requesting our services?
YESNO
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What is your primary language? * 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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Enter only your street address* This field is required.Do not include City or ZIP. You'll give this in the next question.
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Enter only your ZIP code* This field is required.
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Enter only your city* This field is required.
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Does the patient have MediCAID (OHP)?
YESNO
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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
Self pay (out of pocket)
BlueCross BlueShield
Moda
Pacific Source
Providence
CareOregon
OHP
OUT OF NETWORK: Aetna
OUT OF NETWORK: Cigna
OUT OF NETWORK: First Health
OUT OF NETWORK: Kaiser
OUT OF NETWORK: United Healthcare
OTHER
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We are unable to bill Aetna on your behalf; however, we can provide you with a superbill to submit to your Aetna plan for reimbursement of upfront costs out of pocket.If you would like to proceed with the knowledge that you will need to pay out of pocket and seek reimbursement from Aetna, please select YES. If you are unwilling to proceed having understood this requirement, please select NO or simply discontinue completing the remainder of this form.
YESNO
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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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Do you have secondary insurance coverage? Please note: We do not bill commercial secondary insurance; however we DO bill OHP Medicaid as secondary insurance. If you have secondary commercial coverage you would like to use, we can help support you by providing a superbill and education for understanding the process of submitting superbills to your secondary insurance.
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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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Person seeking therapy: Name* This field is required.
First Name
Last Name
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Person seeking therapy: Date of Birth* This field is required.
Date
Month
Day
Year
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If pediatric, name of legal guardian.* This field is required.
First Name
Last Name
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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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Please list any current medical diagnoses* This field is required.
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I am interested in* This field is required.People are often confused as to what a speech-language pathologist does versus an occupational therapist. The following will help you request more accurately. However, if you are still unsure which therapy you need, simply select "Not sure". Speech-language therapy: speech production, language use, auditory processing, understanding verbal and nonverbal communication, interacting with others, social skills, cognition, attention, learning and memory, voice and respiration, AAC and talking software, feeding & swallowing Occupational therapy: fine and large motor coordination, balance, sensory integration, emotional processing, attention and learning, completion of daily routines (dressing, bathing, feeding self), sensory feeding and positioning.
Not sure
Speech Therapy
Occupational Therapy
Both speech and occupational therapy
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Please select all areas of need observed* This field is required.Scroll through and select as many areas as needed
saying sounds accurately
language use and # of words
ease of speech (stuttering)
AAC and talking software
interacting with others
being understood by others
swallowing
feeding
infant feeding/positioning
transgender voice
problem-solving
attention
sensory processing
balance and coordination
emotional processing
dressing self
bathing self
bathroom needs/ pottying
using utensils and tools
navigating social routines
completing tasks for daily routines
learning new things
hand-eye coordination
something else
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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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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.
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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Is there anything else you would like us to know?
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. You will receive an occasional check-in email to which you can respond to make any changes to any information provided. 3. 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. Because of the variability of availability for different geographical regions, we are unable to give you an estimate for length of time on the waitlist; however, we typically see spots open every 3 - 8 weeks. IMPORTANT: You must have at least TWO DAYS available for treatment. Select YES to indicate that you understand.
YESNO
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