Complete this secure form if you have concerns about your school-aged (5 years old and above) child’s ability to communicate. 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 speech and language (ask doctor’s office to fax to 888-975-7556)
  • Contact information of specialists working with child (if any)
  • Credit Card ($35 appointment deposit)

 (download this form if you prefer to mail your child’s case history to our office)