Therapy Interest Form — Not Too Little Speech Therapy

1. Patient's Full Name *

2. Patient's Physical Address *

3. Patient's Zip Code *

We currently provide services in the zip codes listed below. If you live very close to the boundary, please select "Border Area – Zip Review Requested."

4. Border Area – Zip Review

"Border Area" means directly next to the zip codes above – a street or two outside the line, not a different part of the valley. Common nearby zips we can review: 89117, 89146, 89102, 89106, 89144, 89138, 89031, 89084. Not on that list, or way outside these? See below.

Zip Code

Cross Streets

5. Patient's Birthdate *

Example: January 7, 2019

6. Patient's Insurance Provider *

Please select your child's primary insurance plan, or Self-Pay / Cash Pay.

I'm interested in learning about cash-pay options

7. Was your child referred by a doctor? *

Yes No

8. Does the patient have an established diagnosis? *

Yes No Not sure

If yes, what is the diagnosis?

9. What are your main concerns regarding the patient's communication, language, speech, and feeding/oral function skills? *

10. Is the patient currently receiving or has the patient previously received speech or feeding therapy? *

Yes No

11. If yes, where was the patient seen and by whom

12. Which services are you interested in for your child? *

Early Intervention (Ages 0–3) Speech Sound Therapy (Articulation / Pronunciation) Language Therapy (Understanding and/or Expressing Language) Feeding Therapy Oral-Motor Therapy (Speech or Feeding Related) Orofacial Myofunctional Therapy Not Sure – Evaluation Recommended

13. Caregiver's Full Name *

14. Relationship to Patient *

15. If other, please specify

16. Caregiver's Email Address

17. Caregiver's Phone Number

18. Preferred Method of Contact

Phone call Text E-mail

19. Best Days to Reach You *

20. If a therapy spot becomes available, what days and times are you seeking? *

25. Referral or Medical Records Email (if available)

26. Do you authorize Not Too Little Speech Therapy to contact the patient's primary care provider?

Yes No

27. If you selected "Yes," please confirm authorization below – type your name, sign, or both. Type your full name:

×

Or sign here (trackpad, mouse, or touchscreen):

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