• Talk to Me...A Speech Therapy Co., LLC

    Please complete each box of this INTAKE FORM and submit it when finished. This form is needed before therapy can begin. NOTE: Once your child is scheduled for their evaluation, a doctor referral from your child's primary doctor must be faxed to 678-819-2810. IF YOUR CHILD HAS AMERIGROUP OR PEACHSTATE A HEARING EVALUATION IS REQUIRED BEFORE THERAPY CAN BE APPROVED.
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  • Insurance Information

  • Fill out insurance information completely. (We do not accept Wellcare or CareSource). If you will be self pay type 'self" under insurance name.

  • Please fill out if child has secondary insurance

  • Medical History

  • Development/Education

  • Consent For Exchange Information, Payment, Evaluation & Treatment and Privacy Policy

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