For best results, please fill this form out on desktop or laptop instead of a mobile device.

Intake Form

"*" indicates required fields

Step 1 of 6

Your Child's Safety is Our Top Priority

In order to ensure the safety of your child during his/her in-home therapy session, it's imperative that an adult be present in your household at all times. While it's not mandatory that a parent/caregiver join the actual session, it can be beneficial.

Note: This form provides developmental milestones and information necessary to better understand your child as we move forward.

Patient Info

Patient Name*
Select date MM slash DD slash YYYY
Sex*
Address*
License and Insurance
How would you like to share your License and Insurance information?
You may upload digital copies of the front and back of your insurance card and license here. Allowed files: PDF, Word Docs, JPG, & PNG.

*IMPORTANT: when uploading files, a red X will appear next to your file. This does not mean an error. The X is to remove the file you uploaded in case you upload the wrong file by mistake. PLEASE ALSO ENTER YOUR INSURANCE CARD DETAILS IN THE INSURANCE SECTION BELOW

Drop files here or
Accepted file types: doc, docx, jpg, jpeg, pdf, png, Max. file size: 100 MB.
    Will therapy need to be conducted outside the home?*
    I travel to your child at the parent/guardian home. Is there an alternate location outside the home to visit? Eg, daycare, babysitters, church, preschool program?

    Referral Questions

    How did you learn about Advantage Speech Therapy Services?

    Parent/Caregiver Info

    Select date MM slash DD slash YYYY
    Address
    Alternate Phone Type
    What is the best form of communication to reach you?*
    (Check all that apply)
    Employment Info #1
    Is there a second Parent/Caregiver?