Tell Us About Your Child
Tell us a little about your child and what you’re noticing. We’ll review your request and contact you about possible next steps. After sending your request, you can schedule your 15-minute intake call on the confirmation page. This is a request, not a booked therapy appointment or a commitment to services.
Which location are you inquiring about?
*
Westchester, NY
Chicago, IL
About Your Child
Child's First Name
*
Child's Last Name
*
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child’s age (approximately)
Primary Language Spoken at Home
Parent / Guardian
Parent / Guardian Full 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
Call
Text
Email
Any
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What brings you here?
Please check all that apply
*
Articulation / Speech Sounds
Expressive Language
Receptive Language
Fluency / Stuttering
Voice
Social Skills / Pragmatics
Literacy / Reading
Not Sure / Need Guidance
What would you like us to know about your child? A sentence or two is enough.
*
Has Your Child Received any diagnoses?
*
Has Your Child Received Speech Therapy Before?
*
Yes
No
Not Sure
Which payment option would you like to explore? Choosing an option does not commit you to services.
*
I have Cigna and would like to check my in-network benefits
I would like to pay Baker Speech Therapy directly
I have another commercial insurance plan and would like to ask about out-of-network claims
I am not sure yet—please help me understand my options
Will you be submitting for insurance reimbursement through out-of-network benefits? By selecting Yes, you understand that reimbursement is not guaranteed, depends on your family’s individual benefits, and payment is due at time of service.
*
Yes
No
Insurance Carrier
One last thing (optional)
Preferred Days
*
Monday
Tuesday
Wednesday
Thursday
Friday
Flexible
Preferred Times
*
Mornings
Afternoons
After School
Flexible
How Did You Hear About Us?
Please Select
Pediatrician or doctor referral
School or preschool
Friend or family
Google / web search
Social media
Early Intervention
Other
Anything Else We Should Know?
Send My Request
Should be Empty: