Speech Therapy Enrollment Form

1
Who will be receiving services?* This field is required.
My Child
Myself
2
Your Name* This field is required.Please enter your full legal name.
3
Your relationship to the client* This field is required.
My Child
Self
A family member
Legal Guardian
4
Client Name (If under 18)* This field is required.
5
Client's Date of Birth * This field is required.
Date
Year
Month
Day
6
Phone Number* This field is required.
Please enter a valid phone number.
7
Email* This field is required.
example@example.com
8
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
Upload photos of the Primary Insured's Drivers License * This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
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10
Is the client a child in a divorced or separated household?* This field is required.
YESNO
11
Contact #2 Name * This field is required.Required if client is a child in a divorced or separated household and both parents have legal custody
12
Contact #2 Relationship to Client * This field is required.
13
Contact #2 Phone Number * This field is required.
Please enter a valid phone number.
14
Contact #2 Email Address * This field is required.
example@example.com
15
Who is your insurance carrier?* This field is required.
Blue Cross Blue Shield (BCBS)
Blue Care Network (BCN)
Aetna
Out-of-Pocket
16
Upload photos of insurance card (front and back)* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
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17
Primary Insured's Date of Birth * This field is required.
Date
Year
Month
Day
18
Why are you looking to begin speech therapy?* This field is required.
Articulation Disorder(s)
Stuttering
Dysphagia (Difficulty swallowing)
Social Communication
19
What is the client's availability?* This field is required.
Morning (9am-11am)
Afternoon (12pm-4pm)
Evening (5pm-8pm)
20
Which location would you like to receive services in?
Ann Arbor
Farmington Hills
21
Any previous diagnoses received?* This field is required.
Autism Spectrum Disorder (ASD)
Attention-Deficit/Hyperactivity Disorder (ADHD)
Developmental Coordination Disorder (DCD)
Specific Learning Disabilities
Down Syndrome or other genetic conditions
Cerebral Palsy and other neurological conditions
Trauma and/or Stress Disorders (If impacting daily function)
Feeding and Swallowing Disorders
Stroke and Traumatic Brain Injury (TBI)
Multiple Sclerosis (MS), Parkinson's Disease, or other progressive neurological conditions
Mental Health Diagnoses (e.g. Anxiety, PTSD, Depression) when they significantly impact self-care, work, or daily function
Other
22
Speech Therapy Referral or Prescription* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
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23
Please summarize your goals for Speech Therapy* This field is required.
Huge
Large
Normal
Small
Ok
Ok
24
How did you hear about this service? * This field is required.
Should be Empty: