Speech Therapy Interest & Registration Form
Thank you for your interest in speech therapy services with AccessibleTx, LLC. Completing this form will allow us to collect information about your child’s needs and begin the process of adding your child to our interest list, waitlist, or caseload. Please read all instructions carefully.
I have the following concerns (please check all that apply)
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Articulation: Speech sounds - Is your child difficult to understand or sound immature for their age? Do you hear errors in their speech you are concerned about?(e.g., saying “yewo” for “yellow”, “tat” for “cat”)
Expressive Language: Speaking language (e.g., not using language like other kids their age, limited expressive vocabulary)
Receptive Language: Understanding language (e.g.difficulty understanding basic concepts, vocabulary, or learning colors; not following multi-step and simple directions like “Give me book.”)
Pragmatics: Using social rules of language (e.g., not saying “hi” and “bye”, invading others' spaces, not taking turns in conversations, difficulty making friends, uses language in a limited way, difficulty interpreting tone of voice and facial expressions )
Please list any diagnoses.
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If your child receives other services (e.g., Physical Therapy, Occupational Therapy, ABA, Babies Can’t Wait services), please list the location, therapist’s or service coordinator’s name, and contact information.
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Has your child completed any developmental testing? If yes, please upload the report.
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Developmental Testing is Performed by a Psychologist.
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Has your child received speech therapy services at another location within the past six (6) months? If yes, please upload any available reports from those sessions.
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Does your child have an IEP or IFSP? If yes, please upload supporting documents.
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Please attach your child’s hearing screening results, if available.
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Child's Name
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First Name
Last Name
Child's Date Of Birth
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Month
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Day
Year
Date
Parent/Guardian Name
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First Name
Last Name
Parent/Guardian Email
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example@example.com
Parent/Guardian Phone Number
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Please enter a valid phone number.
Primary Insurance Provider
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Medicaid
Caresource
Amerigroup
Private Pay
Insured ID Number (starts with # 222)
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Name of Physician/Agency:
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Phone Number of Physician/Agency
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Please enter a valid phone number.
Fax Number of Physician/Agency
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Please enter a valid phone number.
Important Notice & Acknowledgement Statement
By submitting this form, you are expressing interest in speech therapy services with AccessibleTx, LLC. Please understand that completing this form does not guarantee an appointment or establish a patient–therapist relationship. Your child will only be added to our caseload or waitlist once all required documents have been received, including a physician’s order/referral for evaluation and treatment.You must contact your child’s doctor to have an order/referral faxed to our clinic at 470-289-3840 within two (2) weeks of submitting this form. If we do not receive the referral within this timeframe, your child’s name will be removed from our list, and the process will need to be restarted. Once we have received the order/referral, we will contact you within three (3) business days at the phone number you provided.The information you submit on this form is provided voluntarily and is not considered protected health information under HIPAA until a formal patient–therapist relationship has been established. By completing this form, you consent to AccessibleTx, LLC contacting your child’s physician and/or other relevant agencies as needed to gather or release information in support of your child’s care. This information will be used solely to ensure the best possible quality of care if services are initiated.
I have read and understand the above information, and I agree to comply with these requirements. I understand that selecting “I DO NOT understand” will void this submission and my child will not be added to the list.
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You must contact your child’s doctor to have an order/referral faxed to our clinic at 470-289-3840 within two (2) weeks of submitting this form. If we do not receive the referral within this timeframe, your child’s name will be removed from our list, and the process will need to be restarted. Once we have received the order/referral, we will contact you within three (3) business days at the phone number you provided.
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I understand.
I DO NOT understand.
Thank you!
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