• Intake Form

    Kids Social Classes
Gold Speech Individual Intake Form

Gold Speech Individual Intake Form

Click here to enroll in our social language classes for children!

Note: Gold Speech does not accept insurance. We will provide a monthly statement which you can submit to your insurance for reimbursement. Dawn Gold and her Associates are considered out-of-network and are not affiliated with any insurance companies.

Your personal information will be kept strictly confidential and will only be viewed by Gold Speech for the purposes of scheduling speech therapy services. By completing this form, you enable Gold Speech to initiate a conversation with you about scheduling services for you or your child. Because we offer home-based speech therapy, it is necessary to know the address in advance in order to match geographical coverage areas with scheduling availability. Thank you! ​

    Your Contact Information

    Referral source: *

    AVAILABILITY TO BE SEEN

    Select the type of service you desire: *

    8:00 AM - 2:30 PM weekday in-person services3:00 PM or later weekday in-person services (waitlisted)Virtual telehealth services weekdays or weekends

    Is it a possibility to see your child at preschool / daycare / private school? *

    yesunsure, I will asknon/a

    Would you potentially be interested in a children's social language group to work on skills like cooperation and collaboration with peers, turn-taking, back-and-forth conversation and understanding others' perspectives? *

    Please list ALL available days and times. The more possibilities you list, the greater the likelihood we can help you. Note that individual sessions are generally 45 minutes weekly or 30 minutes twice weekly.*

    Client Information

    Client's Date of Birth:* (MM/DD/YYYY)

    Grade in 2023-24 and name of school, if applicable:*

    Languages spoken in the home *

    Pet Information

    Do you have pets in your home?:*

    Previous Evaluations

    Has an evaluation been done by a speech pathologist to address the concern(s)? Please check all that apply:*

    Have other specialists already evaluated your child? Please check all that apply:

    You may upload relevant files such as previous evaluations, progress reports, IEPs, IFSPs, audiology results, etc.

    2nd file if applicable

    Nature of the Problem

    Please list any relevant diagnoses:

    What are your concerns? Please check all that apply:*

    Please tell us how we can help you:*

    Are there any challenging behaviors we should be aware of?*

    INSURANCE REIMBURSEMENT FROM YOUR PPO

    Will you need a statement to submit to insurance for reimbursement of services?*

    If yes, what insurance carrier provides your medical coverage? This question is informational only to help us determine appropriate codes to include on your superbill. We do not handle claim submission or phone calls to your insurance company.*

    Coverage areas

    MAP COVERAGE AREAS