Referral Form
Shira Habermehl, M.S. CCC-SLP
Date
-
Month
-
Day
Year
Date
Your Full Name
First Name
Last Name
Your Role
Role
Child's Name
First Name
Last Name
Child's Date of Birth
-
Month
-
Day
Year
Date of Birth
Child's Age
Parent/Guardian(s) Full Names and Relationship to Child
Primary Guardian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Child's Primary Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary language spoken at home
Other language(s) spoken at home
Reason(s) for referral (check all that apply)
Augmentative and Alternative Communication (AAC) Evaluation Request
AAC-related speech and language services (in-person or teletherapy) request
Other
Is the parent/guardian aware of this referral?
Yes
No
If no, please state why not
Name of Pediatrician/Primary Care Provider
What health insurance plan does the family have?
What other service(s) are the child and/or family receiving?
DCF/Family Services
Children's Integrative Services (CIS)
Head Start
Howard Center
Luse Center
The Family Room
Lund
Not Sure
Other
What other service(s) are the child and/or family receiving?
DCF/Family Services
Children's Integrative Services (CIS)
Head Start
Howard Center
Lund
The Family Room
Luse Center
Not Sure
Other
What service(s) has the child received previously or is currently receiving AT HOME?
Speech and Language (SLP)
Applied Behavior Analysis (ABA)
Occupational Therapy (OT)
Physical Therapy (PT)
Special Education
Not Sure
What service(s) has the child received previously or is currently receiving AT SCHOOL?
Speech and Language (SLP)
Applied Behavior Analysis (ABA)
Occupational Therapy (OT)
Physical Therapy (PT)
Special Education
Not Sure
Has the child had a hearing test? (physician, other)
Yes
No
Not Sure
Pass
Have they been referred to an audiologist? If yes, when?
Has the child had a vision test? (physician, other)
Yes
No
Not Sure
Pass
Have they been referred to an optometrist? If yes, when?
Does the child attend school?
Yes
No
Not Sure
Program/School Name and Location
Days/Times of School Attendance
Did you receive verbal and/or written permission from parent/guardian for Shira Habermehl to talk with the child's teacher/speech language pathologist (if applicable)?
Yes
No
What do you hope will happen as a result of this referral?
If you have any questions about the referral form or general questions about services, don't hesitate to reach out at shira@flowstateslp.com, 802-448-0627 or visit our website at flowstateslp.com
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