1. Language Link Therapy - Request for Therapy

Welcome to the Language Link Therapy family!

To begin the process of establishing care, we kindly ask you to complete this short request form. Once submitted, you'll receive a welcome email with next steps.

If you have any questions, feel free to call or text us at 954-689-0730, or send an email to info@therapyfl.com. We're here to help!

Patient First Name (Child)

Patient Last Name (Child)

Patient Date of Birth

Date

Does Patient have a diagnosis of Autism?

YesNo

What city does Patient reside?

Caregiver Name

First NameLast Name

Caregiver Cell Phone

Please enter a valid phone number.

Caregiver Email

example@example.com

Caregiver Relation to Patient

ParentGrandparentFoster ParentOther

Primary Insurance

Secondary Insurance (If applicable)

Third Insurance (If applicable)

Is Patient enrolled in Early Steps

YesNo

Is Patient enrolled in ABA

YesNo

What Services Are Being Requested (Select all that apply)

Speech TherapyOccupational TherapyPhysical Therapy

Please provide any details in which you feel are important for us to know