Referral Partner Intake Form
Chaplin Learning Solutions, LLC
Thank you for your interest in becoming a trusted referral partner. This information will help us connect families with qualified providers who best meet their needs.
Provider Information:
Full Name:
*
First Name
Last Name
Credentials (Ph.D., Psy.D., CCC-SLP, OTR/L, BCBA, etc,):
*
Professional Title:
*
Practice/Organization Name:
*
Website:
*
Primary Email:
*
example@example.com
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Office Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Services Offered (Please check all that apply):
Psychoeducational Evaluations
School Psychology Services
Independent Educational Evaluations (IEEs)
Speech-Language Therapy
Occupational Therapy
Physical Therapy
Applied Behavior Analysis (ABA)
Behavior Consultation
Academic Tutoring
Executive Function Coaching
Counseling/Mental Health Services
Social Skills Groups
Transition Planning
Assistive Technology
Early Intervention Services
Other
Populations Served (Age Ranges):
Birth - 3
Preschool (3-5)
Elementary
Middle School
High School
Adults
Areas of Expertise (Check all that apply):
Autism Spectrum Disorder
ADHD
Learning Disabilities
Dyslexia
Developmental Delays
Emotional/Behavioral Needs
Intellectual Disabilities
Gifted Education
Speech/Language Disorders
Executive Functioning
Transition Services
Other
Service Delivery
Do you offer:
In-Person Services
Virtual Services
Counties Served:
Miami-Dade
Broward
Palm Beach
Monroe
Other
Insurance & Payment Information
Do you accept insurance?
Please Select
Yes
No
If yes, please list plans accepted:
Private Pay Rates: (Optional)
Do you offer payment plans?
Please Select
Yes
No
Current Wait Time for New Clients:
Immediate Availability
1-2 Weeks
3-4 Weeks
1-2 Months
Other
Preferred Referral Types:
Professional Background
Years of Experience:
Licensure Information:
Specialized Certifications/Training:
Collaboration
Are you willing to collaborate with schools and familites regarding student supports?
Yes
No
Only schools
Only families
Are you interested in receiving referrals from Chaplin Learning Solutions, LLC?
Yes
No
Are you interested in reciprocal referrals?
Yes
No
Additional Information
Please share anything else that would help us understand your services and expertise:
Supporting Documents
Browse Files
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Choose a file
Please attach any of the following: Professional Resume/CV, Professional License/Certification, Service Brochure (if available), Business Card, Website/Social Media Information
Cancel
of
Consent
I certify that the information provided is accurate and understand that submission of this form does not guarantee inclusion in the Chaplin Learning Solutions, LLC referral network.
Signature
Date
-
Month
-
Day
Year
Date
May Chaplin Learning Solutions, LLC share your contact information with families seeking services?
Yes
No
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