Connect with ASTS:

Forms

Please print and fill out the following forms as they apply to you based on the descriptions below. Then, either fax them to (678) 624-9599 or scan them to robyn@advantagespeech.com and save the originals for me for my records.

Welcome Letter – for your records only.

Consent and Release of Information – giving me permission to work with your child.

Intake Form – provides me with a little more information on what your child is doing.

Two copies of the Policies and Financial Agreement Form – It explains all possible payment scenarios. Please read this carefully before signing to understand the late fees and other policies that are in place. One copy is for you and one is for me. 

Patient Information Form – This form gives me your doctor information, your address/email etc. and your payment info. Please be as specific as possible so I know how to reach you or your doctor. If you have already provided me with your insurance info etc. you can just write "ON FILE" in this area. 

For those children between the ages 0-3 and outside the Babies Can’t Wait Program, please fill out the Infant/Toddler Communication Screening: Careprovider Report to help me understand how your child currently understands you and communicates with you.

If you feel as though there is more important medical history that is not covered on any of these forms, feel free to fill out the Case History so that I can best understand and meet your child's needs.

Copies of insurance card and driver's license. 

 

Having trouble reading our forms? You may need to download Adobe® Reader®.

 

Download our forms directly from the links below:

AttachmentSize
01 IntakeFormASTS.pdf76.78 KB
02 Polices and Financial Agreement Form.pdf149.8 KB
03 Patient Information Form.pdf90.47 KB
04 Case History.pdf175.25 KB
05 WELCOME LETTER.pdf59.41 KB
06 Consent & Release of Info.pdf99.43 KB