WELCOME PACKET

Please list age at which child has achieved the following

Speech Start, LLC requires payment for all services provided at time of service, NO EXCEPTIONS. At no time will any service be delivered without receipt of payment. A receipt will be issued for all paid-in-full services. Reduplication of receipts and or reports can be supplied at a fee of $25.00 per request payable in advance. Checks made out to Speech Start, LLC, cash, and credit/debit cards are accepted. A 10% late fee will be charged monthly and addded to your bill 30 days overdue and service will be terminated. Termination of service is considered valid with a two week written notice to Speech Start. Any service discontinued without the two week written notice is billed at the full rate and subject to a 10% late fee.

Speech Start, LLC requires payment for all services provided at time of service, NO EXCEPTIONS. If payment is not received by 7:00 pm on the date of service, the client’s card on file will be automatically billed. A receipt will be issued for all paid-in-full services upon request. Checks made out to Speech Start, LLC, cash, and credit/debit cards are accepted. A 10% late fee will be charged monthly and addded to your bill 30 days overdue and service will be terminated, In addition, any bounced checks will be subjected to a $50 returned check fee, which will be added to the client’s balance. Termination of service is considered valid with a two week written notice to Speech Start. Any service discontinued without the two week written notice is billed at the full rate and subject to a 10% late fee.

Please upload a copy of the front & back of the insurance card & policy holder license.

Speech Start LLC requires that all clients place a credit card on file, regardless of preferred payment type. The credit card will only be charged for services rendered and information will be kept private. If payment is not received by 7:00 pm on the date of service, the client’s card on file will be automatically billed. A 10% late fee will be charged monthly and addded to your bill 30 days overdue and service will be terminated. List CC info here but also have them check a box to indicate whether or not card is credit, debit, or HSA/FSA/Medical Card

Speech Start LLC is enrolled in the Cash Discount Program for payments. You are welcome to use credit/debit cards for payments to reap the rewards offered by your issuing card brands. In consideration of keeping our costs as low as possible to our valued clients, we chose to not increase our costs for our services provided to you and allow you to decide how to pay. Subsequently, all charges for services will automatically incur a 3.75% processing fee. This applies to all card types. If you would rather pay by cash, Speech Start LLC will issue a discount of 3.75% (the service cost), and charge only the original base price of our services.

Speech Start LLC completes thorough evaluations/re-evaluations that may require more than one visit (or separate visits in addition to regular therapy sessions) depending on the needs of the client and their family. There is no guarantee that evaluation testing will be completed in a single session.

Speech Start LLC completed a detailed written evaluation/re-evaluation report in addition to our documentation system’s evaluation report. The detailed written evaluation/re-evaluation report will be shared with the client’s guardian(s) within 30 days of the last date of testing. Guardian(s) may request a meeting to discuss the testing results and to answer any questions but there is no guarantee of such a meeting within a specific timeframe. Furthermore, meetings must be attended by one or both of the business owners along with the child’s therapist(s) (if possible but not guaranteed). Any meeting outside of the initial evaluation report discussion meeting (for new clients only) with a client’s guardian(s) or other service professionals, can be offered at the expense of the client (based upon type and length of meeting with additional charges for number of Speech Start LLC professionals in attendance). New clients are offered one initial meeting to discuss findings at no cost not to exceed 60 minutes.

Speech Start LLC requires that all clients/families communicate to the business office directly regarding but not limited to missed appointments, test results, meeting appointments, issues, etc. Clients and their families are not permitted to communicate directly with current or past staff members via private phone numbers, emails, or social media accounts. Doing so may result in immediate termination of services at Speech Start LLC.

Speech Start LLC requires 24 hours written (email) and verbal (phone call) notice for a cancellation with the exception of illness or emergency. We also request that clients provide specific information as to which services they will not be attending particularly if multiple services are scheduled on the date of service. Speech Start LLC waives the no show/late cancellation fee for the first missed appointment. If a second no show/late cancellation occurs, the client is automatically billed $35 for each service missed. After the second no show/late cancellation, the client is automatically billed the full rate for each service missed based upon the time scheduled (i.e. if the client missed a 30 minute OT session and a 45 minute speech session, they will be charged $60 + $88.50 = $148.50).

In addition, when/if repeat cancellations occur (more than 50% of appointments for the month are cancelled/no show appointments). Speech Start LLC may suggest discontinuing services at that time.

Speech Start LLC requires 2 week’s written notice of any discontinuation of services (as per the request of the guardian) without discharge. Any service discontinued without the two week written notice is billed at the full rate and subject to a 10% late fee. Furthermore, Speech Start is not required to complete a discontinuation of services report or other documentation if proper notice is not provided.

Speech Start, LLC is occasionally requested to submit information for clients to insurance companies, school districts, physicans, or other therapists. We cannot do so unless we have your written consent. We also may ask for and obtain information from outside sources regarding your child in order to provide quality service. By signing below, you authorize Speech Start, LLC to release information and/or acquire information about your child during the course of evaluation or treatment for medical, professional, or insurance purposes. Photocopy of this authorization shall be considered as effective and valid as the original.

By signing below, you hereby authorize Speech Start, LLC to take or aquire photo, video, or audiotypes of your child, during evaluation and/or treatment for intervention purposes only. The photo, video, or audiotapes will not be released to outside parties without permission from the parent(s) / guardian(s). By signing below, you also hereby release Speech Start, LLC from liability for any claims by you or any third party in connection with your participation.

By signing below, you hereby authorize Speech Start, LLC to take or acquire photo, video, or audiotapes of your child during therapy for use on print, online, and video-based marketing materials, as well as other company publications. By signing below, you also hereby release and hold harmless Speech Start, LLC from any reasonable expectation of privacy or confidentiality associated with the images above. I also acknowledge that your participation is voluntary and you will not receive compensation for photo, video, or audiotapes taken of your child. By signing below, you finally hereby release Speech Start, LLC , its contractors, its employees, and any third parties involved in the creation of publication of marketing materials, from liability for any claims by yourself or any third party in connection with your participation.

Rates were updated on 03/01/2024

As of 11/6/23, please be advised that Speech Start will require at least 24 hours notice for all cancellations. Any cancellations with less than 24 hours notice will be subject to a cancellation fee of $35. If a client does not show to the time of the appointment without giving notice or calls to cancel minutes before their session, they will be charged the full rate of the session (Please see Service Rates document). If a client cancels less than 24 hours more than three times, they too will pay the full rate for the session.We require a 24 hours notice for a cancellation. In addition, when/if repeat cancellations occur (more than 50% of appointments for the month are cancelled/no show appointments), Speech Start may suggest discontinuing services at that time. We would like to thank you for your continued patronage and support of Speech Start LLC. We feel privileged to provide services to you and your family. If you have a personal issue that you would like to discuss regarding attendance please call Dr. Mullen at (732) 888-3912. First time no show/late cancellation - No charge Second time no show/late cancellation - $35 late fee Third time no show/late cancellation - Out of pocket rate ($60 - half hour or $88.50- 45 mins) By signing below, you understand that any fees rendered to your child is your responsibility, and you agree to pay for these services in full delivery, regardless of your child's attendance. If you have any questions regarding payment, please see front desk.

All clients must give at least 2 weeks' written notice when discontinuing services. All sessions within that time period must be attened in order to receive a discontinuation of services report. By signing below, you understand that any fees rendered to your child, is your responsibility, and you agree to pay for these services in full prior to service delivery, regardless of your child's attendance. If you have any questions regarding payment, please see front desk.

As of 11/6/23, please be advised that Speech Start will require at least 24 hours notice for all cancellations. Any cancellations with less than 24 hours notice will be subject to a cancellation fee of $35. If a client does not show to the time of the appointment without giving notice or calls to cancel minutes before their session, they will be charged the full rate of the session (Please see Service Rates document). If a client cancels less than 24 hours more than three times, they too will pay the full rate for the session.We require a 24 hours notice for a cancellation. In addition, when/if repeat cancellations occur (more than 50% of appointments for the month are cancelled/no show appointments), Speech Start may suggest discontinuing services at that time. We would like to thank you for your continued patronage and support of Speech Start LLC. We feel privileged to provide services to you and your family. If you have a personal issue that you would like to discuss regarding attendance please call Dr. Mullen at (732) 888-3912. First time no show/late cancellation - No charge Second time no show/late cancellation - $35 late fee Third time no show/late cancellation - Out of pocket rate ($60 - half hour or $88.50- 45 mins) By signing below, you understand that any fees rendered to your child is your responsibility, and you agree to pay for these services in full delivery, regardless of your child's attendance. If you have any questions regarding payment, please see front desk.