Complete this secure form if you have concerns about your child’s feeding or diet. If you have not already provided a copy of the listed documents previously, you will need:

  • Approximately 20 minutes to complete
  • Photo of insurance card (Does Atlanta Speech Therapy accept my insurance?)
  • Individualized Education Plan (required by all Medicaid insurances, if applicable)
  • Pediatrician prescription for evaluation and treatment of feeding difficulties (ask doctor’s office to fax to 888-975-7556)
  • Contact information of specialists working with child (if any)
  • Credit Card ($35 appointment deposit is required when you do not already have a scheduled appointment)