INDIVIDUAL THERAPY REQUEST

Due by August 2nd, 2024 - NO EXCEPTIONS! *Forms are considered in the order they are submitted! Speech Start's Fall 2024 individual therapy schedule request form for speech/language, feeding, and/or occupational therapy as well as academic services. We will try our best to accommodate you but can not guarantee that you will receive the exact day and time that you have requested on this form. Fall schedule will begin on Tuesday, September 3rd. Speech Start is closed on Monday September 2nd, 2024 for Labor Day Currently, we accept Aetna, United Healthcare and Horizon BCBCS insurance plans for speech/language/feeding/OT therapy. Tutoring is out of pocket only! Please contact our office for specific rates and/or coverage information!

Child's Name(Required)
Please enter a number less than or equal to 99.
Parent/​Guardian's Name(Required)
We will try our best to link up speech and occupational therapy services for your child
We will try our best to link up speech and occupational therapy services for your child
Duration of Weekly Session(Required)
60 Minute Sessions are for Out of Pocket Payers Only!
Preferred Weekday(Required)
Preferred Location(Required)
Preferred Mode of Service Delivery(Required)
Virtual Services may NOT be covered by your insurance company! Please check your policy's coverage before requesting virtual sessions for your child!
Preferred Therapist (Choose ONLY 3)(Required)