INFORMATION ABOUT YOU
This is for the person filling out this form.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone
*
THE PERSON RECEIVING SPEECH THERAPY
This section is about whoever received the therapy services, whether that's you or someone else.
Are you sharing your own experience or someone else's?
*
I am sharing the experience of someone else (my child, my parent)
I am sharing my own experience
Who are you sharing this story about?
*
my son
my daughter
my spouse
my mother
my father
my family member
What is your child's age?
*
Enter your child's current age in years.
What is the name of the person whose story you are sharing?
*
If you are sharing your own experience, you can leave this blank.
Patient's Zip Code
*
Please enter the ZIP Code where the person receiving speech therapy lives.
Name of Clinic / Provider
*
Enter the name of the clinic, practice, or provider where speech-language therapy is received.
City where speech-language therapy is received.
*
State where speech-language therapy is received.
*
Have any of the following made speech-language therapy difficult to access or continue? Select all that apply.
*
Long waitlists
Not enough speech-language pathologists in my area
Difficulty finding a provider accepting new patients
Difficulty finding a provider who accepts my insurance
Insurance coverage or authorization problems
My therapist left or changed jobs
Scheduling availability
Long travel distance
The clinic reduced services or availability
Cost
None of these
Other
Tell us more about how these access challenges affected you or your family.
THERAPY IMPACT AND ADVOCACY MESSAGE
Tell your story in your own words. Each question below focuses on a different part of your experience.
Before speech-language therapy, what was difficult for you or your loved one?
*
Tell us what life was like before therapy. You might describe challenges with speaking, understanding language, communicating with family, eating or swallowing, memory, school, work, social communication, or everyday independence.
What can you or your loved one do today that was difficult or impossible before speech-language therapy?
*
Be specific. Think about things like talking with family, communicating wants and needs, being understood, eating safely, succeeding at school, returning to work, holding a conversation, or living more independently.
What has your speech-language pathologist done that made a real difference?
*
Tell us about your therapist's role in your progress. What did they help you or your loved one achieve? What would have been different without their care?
What would it mean for you or your loved one if speech-language therapy became harder to access?
*
Think about what could happen if your clinic had fewer therapists, longer waitlists, reduced services, or could no longer provide care. How would that affect communication, health, school, work, independence, or your family?
If you could say one thing directly to federal decision-makers about why access to speech-language therapy matters, what would you want them to know?
*
Don't worry about making it sound formal. Write it in your own words. We want decision-makers to hear directly from patients and families.
ELECTRONIC SIGNATURE AND AUTHORIZATION
Electronic Signature (Full Legal Name)
*
First Name
Middle Name
Last Name
Date Signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Letter Opening
Submit
Should be Empty: