Rise Speech Services Inquiry
Rise Therapy & Wellness is excited to welcome our new neuroaffirming Speech & Language Therapist, bringing years of experience and a strengths-based approach that aligns with Rise values. She will begin part-time on Fridays starting December 12, with a full-time transition on February 1. To make sure we launch services smoothly and fairly, we’re asking anyone interested in speech therapy to complete our Speech Services Inquiry Form. We’re grateful to grow in ways that support your child’s communication, confidence, and overall well-being.
Client Information
Please provide as much details as possible. It is helpful for our administrative staff and providers.
Interested Client's Full Name
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First Name
Last Name
Client's Date of Birth (DOB)
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Month
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Day
Year
Date
Caregiver's Full Name (If client is under 18 years old)
First Name
Last Name
Client Contact Information - Client or caregiver's phone number
*
Format: (000) 000-0000.
Client or Caregiver's Email Address
*
example@example.com
Referral Information
We require a referral for all rehabilitation services, including speech therapy, occupational therapy, and physical therapy—regardless of your insurance requirements. A referral ensures that a licensed medical provider reviews and signs off on our plan of care and can monitor your child’s progress. Additionally, many insurance companies do require referrals.If you do not have a referral, please contact your medical provider to request one. We are unable to schedule an evaluation without it. If you have questions you may email us at connect@risetherapyandwellness.org and we will walk you through the process.
Do you already have a referral for speech and language (SLP) services?
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Yes
No
Unsure
Primary Care Physician or Referring Provider
First Name
Last Name
Location of Practice
For example, Bronson Family Practice, etc.
Client History
Has your child ever had speech and language services?
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Yes
No
I do not know
Brief description of Speech and Language Concerns
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What is your biggest goal for speech and language services?
If unsure, just indicate above. We will work with you to help develop and prioritize meaningful goals.
Speech & Language Support Areas; please indicate if you or someone you're caring for requires support with:
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Speech clarity & articulation: support for producing sounds clearly so communication feels easier and more confident.
Speech motor planning / Apraxia: Support for coordinating the movements needed for speech.
Language development: Support for building understanding of language and expanding expressive communication (verbal, AAC, gestures, signs).:
Stuttering / Fluency: Support for communication that feels steady, comfortable, and confident.
Feeding skills: Support for safe, regulated, and confident eating skills; oral-motor coordination; sensory exploration of foods.
Receptive language: Support for understanding spoken language, following directions, and processing information in a way that works for the child’s brain.
Expressive language: Support for sharing wants, needs, ideas, stories, and social connections in any communication style.
Social communication: Support for building connection, perspective-taking, conversational skills, and navigating interactions in authentic and respectful ways.
Reasoning / Memory / Cognitive-communication: Support for problem solving, sequencing, memory strategies, and functional day-to-day communication skills.
ASD and other neurodivergent communication differences: Support for communication needs related to Autism Spectrum Disorder and other neurodivergent conditions, using neuroaffirming, sensory-aware, and strengths-focused approaches
Craniofacial differences: Support for speech, feeding, and resonance needs for children with cleft lip/palate or other craniofacial conditions.
Unsure
Other
Space to share anything unique to your child’s communication needs.
Availability
Our new neuroaffirming Speech & Language Therapist has officially began full time. Please indicate your availability below.
What are your preferred days?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
What are your preferred times?
Morning
Afternoon
Evenings
Flexible/Open availability
Comment
Comment if want us to know more about your availability.
Insurance or Private Pay
Will you be billing insurance or interested in private pay options?
Do you have insurance?
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Yes
No
Private Pay
Unsure
Primary Insurance
*
If not applicable, indicate with N/A
Member ID
*
If not applicable, indicate with N/A
Subscriber's First and Last Name
*
If not applicable, indicate with N/A
Last Name
Subscriber's Date of Birth
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Month
-
Day
Year
If this not applicable, please indicate by entering 01/01/2001 or any date will work
Today's Date:
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Month
-
Day
Year
Date
Are you a current Rise Therapy & Wellness occupational therapy client?
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Yes
No
Scheduled by not yet seen
Unsure
Rise Therapy & Wellness
8599 N. 32nd Street Suite 102, Richland, MI, 49083; Phone: 269-203-7394 Email: connect@risetherapyandwellness.org; Web: www.risetherapyandwellness.org
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