• Date Format: MM slash DD slash YYYY
  • Caregiver:

  • Emergency Contact:

  • Referral Source:

  • Insurance Information:

  • Medical History:

  • Have you had problems with or changes in (check all that apply):

  • Hearing:

  • Vision:

  • Teeth:

  • Education and Work History

  • Language(s) Spoken

  • Communication and Language

  • Additional Information

  • I am granting permission for Chandler Speech and Language Services to evaluation and provide treatment recommendations as clinically necessary. Attendance is a critical factor with regard to therapy services.

    I understand that if I need to cancel my appointment I must do so within 12 hours of the appointment time. If I fail to do so, Chandler Speech and Language has the right to charge a no-show fee of $50.

    If I miss 3 consecutive sessions of therapy, Chandler Speech and Language has the right to place services on hold until scheduling may be resolved.

    My signature indicates that, to the best of knowledge, all information provided above is accurate and current. My signature indicates I am in agreement with all policies presented above.

    I acknowledge that it is my responsibility that if my insurance changes at any time or fails to cover any services, I may be responsible for any remaining balance.

  • Date Format: MM slash DD slash YYYY
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