New Patient Form- Please complete and submit online before 1st visit

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.
Child's Full Name

First NameLast Name
Birth Date

MonthDayYear
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number ( Please type the number of the main person we will contacting to set up appointments and reminders. Only ONE family member will be contacted for reminders)*

Area CodePhone Number
E-mail
Child's Medical Diagnosis
Pediatrician's Name*
Pediatrician's Phone Number
Pediatricians Fax Number
How were you referred?
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.
Name of Insurance*
Full Name of Insurance Holder

First NameLast Name
Insurance Holder's Relationship to Patient
Insurance Holder date of birth
Insurance Holder Address (If different from child's)
Insurance Provider Phone Number
Insurance ID Number*
Insurance Group Number
Does your child have a secondary insurance?

YesNo
Please fill out if child has secondary insurance
Name of Secondary Insurance
Insurance Member ID:

Medical History
Why are you seeking speech &/or feeding therapy for your child? What are your goals for therapy?
Is your child adopted/in foster care?

YesNo
Please describe your pregnancy/delivery. Was it normal, full term, complications? Please explain
Please list and explain any medical problems your child has
Has your child been hospitalized or had medical procedures?
Please list current medications, frequency, dosages and reasons for meds:
Does your child have known allergies/dietary restrictions?
Has your child ever had a psychological, developmental, neurological, psychiatric, EEG, swallow study, MRI evaluation? If so, why and what were the results? * A copy must be submitted before any therapy services can begin
Did child pass hearing evaluation

YesNo
If no, please explain results:
Did child pass vision evaluation

YesNo
If no, please explain results:

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