The following forms are available for your convenience. These are to be filled out and sent back to us so that the forms arrive in our office TWO DAYS prior to appointments. Please include a copy (front & back) of your insurance card. The front office can help you with these, if needed. The printable forms are in Adobe's PDF format and require Adobe's reader, which can be downloaded for free here.

Forms to fill out - adults in general

• *Adult Intake Sheet and Insurance Information
• Adult Case History Form
• **Notice of Privacy Practice
• Client's Rights, Office Policies, Financial Agreement Form

 

Forms to fill out - voice or VCD clients

• Judging your own voice rating scale
• *Adult Intake Sheet and Insurance Information
• Adult Case History Form
• **Notice of Privacy Practice
• Client's Rights, Office Policies, Financial Agreement Form

 

Forms to fill out - Children's

• *Child Intake Sheet and Insurance Information
• Child Case History Form
• **Notice of Privacy Practice
• Client's Rights, Office Policies, Financial Agreement Form

* Do not include social security number unless we have asked for it.
** You do not need to mail this to us - it is for you to read.

The Speech & Language Stimulation Center accepts most insurance companies including Medicaid. Contact the front office for questions.