Request Speech Therapy Services

Request Speech Therapy Services

Fill out this form to get in touch and schedule an appointment for your child.
Location
Which location are you inquiring about?*

Westchester, NYChicago, IL
475 White Plains Rd., Suite 15 — Eastchester, NY
Chicago, IL location — we will confirm the address when we follow up
About Your Child
Child's First Name*
Child's Last Name*
Date of Birth*

MonthDayYear
Date
Age
Primary Language Spoken at Home
Parent / Guardian
Parent / Guardian First Name*
Parent / Guardian Last Name*
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Best Way to Reach You

CallTextEmailAny
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Areas of Concern
Please check all that apply*

Articulation / Speech SoundsExpressive LanguageReceptive LanguageFluency / StutteringVoiceSocial Skills / PragmaticsLiteracy / ReadingNot Sure / Need Guidance
Tell Us a Little More
Has Your Child Received a Diagnosis?*
Has Your Child Received Speech Therapy Before?*

YesNoNot Sure
Payment

We are a private pay practice. Payment is due at the time of service. We offer courtesy billing, which means we will submit claims to your insurance carrier on your behalf for potential reimbursement directly to you. Reimbursement is not guaranteed and depends on your individual plan.
Will you be seeking insurance reimbursement through courtesy billing?*

YesNoNot Sure Yet
Insurance Carrier
Scheduling Preferences
Preferred Days*

MondayTuesdayWednesdayThursdayFridayFlexible
Preferred Times*

MorningsAfternoonsAfter SchoolFlexible
How Did You Hear About Us?*
Anything Else We Should Know?
Should be Empty:

Request Speech Therapy Services

Location

About Your Child

Parent / Guardian

Areas of Concern

Payment

Scheduling Preferences