Please print and fill out. This form will provide us important information regarding your child’s developmental and medical history. Bring this with you along with your insurance information.
We do require a physician’s prescription be on file prior to any first visit with us. We will contact your doctor for you, but in some cases we may need your assistance. If your child has not seen their physician in a while, some doctors may require this in advance of writing a prescription. If you will be seeing your physician for this purpose, he/she can fax their prescription to us at 614-808-3563. We have included a Physician Referral Form below for your convenience.
Depending on your current health insurance provider or employee benefit plan, it is possible for services to be covered in full or in part.
Please contact your provider to verify how your plan compensates you for speech therapy services. We’d recommend asking these questions to your insurance provider to help determine your benefits:
Payment for assessment and treatment sessions are due at the time of service. For a complete outline or private payment fees, please contact us at email@example.com Credit Card Policy: All clients will complete a credit card authorization form. A credit card will be kept on file for all clients. This credit card will also be utilized in case of late-cancel and no shows.
If you are unable to attend a session, please make sure you cancel at least 24 hours beforehand. Otherwise, you may be charged for the full rate of the session.
Any Other Questions
Please contact us for any additional questions you may have. We look forward to hearing from you!
How do I know if my child needs speech therapy?
Your child may benefit from speech/language therapy if he/she has not met the milestones below by the expected age or if you notice that your child is frustrated by difficulty with communication.
- Uses a different cry to express different needs
- Localizes sounds by turning head
- Uses sounds or gestures to indicate wants
- Frequently coos, gurgles and makes pleasure sounds
- Imitates tongue movements and smiles at familiar faces
- Looks and smiles at people when talked to
- Listens to and imitates some adult speech sounds/intonation patterns
- Babbles using long and short groups of sounds
- Understands phrases like “no-no,” “all gone,” and “bye-bye”
- Makes some appropriate use of gestural language (shake head for “no”)
- Begins to change babbling to jargon
- Uses speech intentionally for the first time
- Says “mama” or “dada” for parents
- Looks for hidden objects
- Points or gestures to communicate or identify needs
- Talks in single words, often omits some initial consonants and almost all final
- Uses echolalia and jargon
- Has 3-20 words (mostly nouns) in expressive vocabulary
- Receptively identify 1-3 body parts
- Follows simple directions
- Uses words more frequently than jargon
- Has an expressive vocabulary of 50 to 100 words
- Has a receptive vocabulary or 300 or more words
- Starts to combine nouns and verbs
- Begins to use pronouns
- Is approximately 25-50% intelligible to strangers
- Names a few familiar objects
- Identifies 5-6 body parts on a doll
- Begins to understand adjectives in phrases
- Speech is 50-75% intelligible
- Consistently uses initial consonants
- Frequently uses medial consonants
- Frequently omits or substitutes final consonants
- Begins to demonstrate turn-taking and sharing behaviors
- Follows simple commands and answers simple questions
- Uses 3-4 word phrases
- Has a receptive vocabulary of 500-900 words
- Has an expressive vocabulary of 50-250 or more words
- Spontaneous sentences approximately 4-5 words long
- Is at least 80% intelligible to familiar listener
- Use of irregular plurals, future tense verbs, conjunctions, and contractions
- Understands object functions
- Has a 1,000-2,000 or more word receptive vocabulary
- Has a 800-1,500 or more word expressive vocabulary
- Appropriately uses is, are, and am in sentences
- Tells 2 events in chronological order
- Consistently uses verbally and grammatically correct sentences
- Completes analogies
- Identifies at least 6 capital letters
- Recognizes absurdities in pictures
- Identifies all basic colors
- Understands passive voice statements
- Likes to pretend and act out stories
- Understands and answers complex 2-part questions
- Significantly reduces number of persistent sound omissions and substitutions
- Uses grammatically correct sentences of 4-8 words
- Follows 3 step directions
- Asks “how” questions
- Uses past and future tenses appropriately
- Uses conjunctions
- Names opposites
- Reduces sentence length to 4-6 words
- Accurately relays a story
- Exchanges information and asks questions
What Does a Speech-Language Pathologist Do?
How Do I Pay for Speech Therapy?
Premier Speech accepts cash, check and credit cards. We are in network with several insurance plans. We are happy to provide the documentation needed to submit to your insurance company for reimbursement if we are not in network with your insurance company. In most cases, you may also use your Health Savings Account or Flexible Spending Account to cover the cost of therapy. Payment is required at the time of service.