• No Obligation Registration Form

    Let's get started, but first some info!

  • For assistance with registration, call our head office at: (416) 96 SPEAK | (416) 967-7325

    If you are completing this form on behalf of another person, please make sure you are legally permitted to access the health-related information for the patient.

    You can legally access the patient's information if:

    • You are the patient yourself
    • You are the parent/legal guardian of a patient under the age of 18
    • You are a licensed physician or nurse who has the consent of the patient to share his/her health information
    • The patient has explicitly permitted you to access his/her health information


    Due to the nature of our hybrid service model, which combines in-home therapy and virtual appointments, we require details regarding your home location, medical history, therapy goals, and schedule preferences to make a suitable match with a registered provider.

  • Contact Information

    The best way to get in contact with you!
  • Are you looking for services for you, or another person?*

  • You selected "For Myself".

    Please fill out the "Primary Contact" information with your information (your name, your phone number, etc)

  • You selected "For Another Person".

    Please fill out the "Primary Contact" information with your information (your name, your phone number, etc)

    Please fill out the Patient Information Fields later in the form with the information of who will be receiving services.

  • Format: (000) 000-0000.

  • For the Secondary Contact Information, please put an additional contact that we may reach out to in case of emergency, or if we are unable to get in contact with the Primary Contact for notifications, questions, and scheduling.

  • Format: (000) 000-0000.
  • With whom does the prospective client / patient reside with?
  • Please choose the most accurate description for the prospective client / patient:

  • Health & Historical Information

    Medical history helps provide a better match across our clinician network!
  • Were you referred by a physician?*
  • Is there a confirmed or suspected diagnosis, developmental delay, or medical condition?
  • Is there a prior history with receiving Speech, ABA, or any other type of therapy?
  • It is the client's responsibility to provide/cover the cost of parking for the therapist. Please indicate whether there is parking available.*
  • When would you like to start appointments?*
     - -

  • NOTE: Therapist and clinician availability times may improve with hybrid or virtual options. If timing is a concern, we strongly recommend considering hybrid or virtual options. 

  • Disclaimers:

    - We do not direct bill insurance companies. When you pay your invoice, you will receive your official receipt within 24-48 hours to submit to your insurance for reimbursement.

    - ABA/Behaviour Therapy Services are not covered by most insurance plans/providers.

    - Cancellation Policy: Any cancellation made less than 24 hours before your next session may be billed the full amount for that session.

    - It is understood and agreed that Speech Inc. shall not be liable for any acts or omissions of the service provider

  • Should be Empty: