1. Language Link Therapy - Request for Therapy

Welcome to the Language Link Therapy Family!

We’re excited to learn more about your child and begin this journey with you. Our onboarding process is simple and streamlined to ensure a smooth start.

To begin, please complete the form below in its entirety. This information allows us to verify your insurance benefits and discuss the details of your coverage with you.

If you have any questions, feel free to call or text us at 954-689-0730 or email us at info@therapyfl.com. We're here to help!
Information about you (caregiver):
Caregiver Name

First NameLast Name
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Caregiver Cell Phone
Please enter a valid phone number.
Caregiver Email
example@example.com
Caregiver Relation to Patient

ParentGrandparentFoster ParentOther
Information about your kiddo
Patient Name

First NameLast Name
Patient Date of Birth

MonthDayYear
Date
Does Patient have a diagnosis of Autism?

YesNoPending Diagnosis
Is Patient enrolled in ABA?

YesNoPending Enrollment
Name of ABA Center
What City is the ABA Center located
Please select the locations in which ABA is currently provided (select all that apply)

In schoolAt ABA CenterAt homeOther
Is Patient enrolled in a daycare/preschool or school?

YesNoPending Enrollment
Name of daycare/preschool or school
What City is the daycare/preschool or school located
What are the hours of attendance for the daycare/preschool or school
Is Patient enrolled in Early Steps

YesNo
Please list all services currently received under Early Steps

Speech TherapyOccupational TherapyPhysical TherapyInfant Toddler Developmental Specialist (ITDS)
Were you requested to call us from your Early Steps coordinator to begin services?

YesNo
Patient First Name (Child)
Patient Last Name (Child)
What city does Patient reside?
Insurance Information
Primary Insurance
Member ID
Secondary Insurance (If applicable)
Member ID
Third Insurance (If applicable)
Member ID
Does the patient have the Step Up Scholarship?

YesNo
Is Patient enrolled in ABA

YesNo
Final Questions
What services are being requested (Select all that apply)

Speech TherapyOccupational Therapy
Please select ALL services the patient is receiving OR have received in the last SIX MONTHS

Speech TherapyOccupational TherapyPhysical TherapyNo Services received in the last (6) months
Do you have a referral from an MD for services?

YesNo
Please provide any details in which you feel are important for us to know
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Should be Empty:

Information about you (caregiver):

Information about your kiddo

Insurance Information

Final Questions