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.