New Patient Forms

HIPAA Privacy Statement

This is a notice of your rights under HIPAA.

Download the PDF

New Patient Forms for Adults

Please obtain a prescription for “speech to evaluate and treat” prior to your appointment or your appointment will be rescheduled.

New Patient Intake Forms

Insurance Verification, Financial Policy, Cancellation Policy, Consent to Treat Forms

This form must be filled out and returned before scheduling your first visit.

Download the PDF

Adult Medical Questionnaire

This form must be filled out prior to first session after appointment is scheduled.

Download the PDF

New Patient Forms for Pediatrics

Please obtain a prescription for “speech to evaluate and treat” prior to your appointment or your appointment will be rescheduled.

New Patient Intake Forms

Insurance Verification, Financial Policy, Cancellation Policy, Consent to Treat Forms

This form must be filled out and returned before scheduling your first visit.

Download the PDF

Pediatric Medical Questionnaire

This form must be filled out prior to first session after appointment is scheduled.

Download the PDF

New Patient Forms for Auto Accidents

Please obtain a prescription for “speech to evaluate and treat” prior to your appointment or your appointment will be rescheduled.

New Patient Intake Forms

Insurance Verification, Financial Policy, Cancellation Policy, Consent to Treat Forms

This form must be filled out and returned before scheduling your first visit.

Download the PDF

Pediatric Medical Questionnaire

This form must be filled out prior to first session after appointment is scheduled.

Download the PDF

Adult Medical Questionnaire

This form must be filled out prior to first session after appointment is scheduled.

Download the PDF

Assignment of Rights Form

This form must be filled out monthly for auto accident patients.

Download the PDF

New Patient Forms for Private Pay Massage Therapy

Massage Therapy Uninsured Medical Case History

This form must be filled out prior to first session after appointment is scheduled.

Download the PDF