Carolina Speech & Myo | SimplePractice

Carolina Speech & Myo Send Message

Who would be receiving care?

Someone else

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Preferred method of contact

phone call text message email I have no preference

Reason for care

What is the reason for seeking care? (check all that apply)

Speech/Articulation Language Feeding/Swallowing Myofunctional Therapy Cognitive Therapy Airway concerns Tongue Tie or Lip Tie Voice Picky Eating Signs of sleep disordered breathing difficulty with breast or bottle feeding sensory issues other other

Tell us a little more about your reason for seeking care.

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What therapy have you had in the past (or are currently receiving)?

speech therapy in the past currently in speech therapy PT OT chiropractic care mental health/counseling Lactation Consultant/IBCLC Cranial Sacral Therapy other no other therapy currently receiving therapy in the home

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Administrative

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Primary Care Doctor or Pediatrician:

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Billing & Payment

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member ID

group ID

secondary insurance

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Policy Holder's name and date of birth

name and date of birth of the policy holder

Client Preferences

Preferred appointment times

Morning Afternoon Evening Weekend

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

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For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.