Sparks of Speech DFW | SimplePractice

Sparks of Speech DFW Send Message

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Child's Name (first and last)

please add the name your child goes by in quotation marks (i.e. "BJ")

Child's Date of Birth and Age

5/3/2020 - 6 years

Child's Gender

Male Female

My child has the following medical diagnoses:

please type N/A if not applicable

Reason for care

I am seeking

select all that apply

Speech/Articulation Therapy Language Therapy Feeding Therapy Augmentative and Alternative Communication (AAC) Therapy Parent/Therapist Consultation

I understand that if Sparks of Speech DFW is unable to meet my child's needs, that I will be notified and provided referrals/resources that may be more appropriate.

Yes

Administrative

How did you hear about us? Who were you referred by?

(Doctor, Dentist, Therapist, social media, etc.)

Billing & Payment

I understand that Sparks of Speech DFW is out-of-network with all insurance companies at this time. I understand that I may be provided a super bill, upon request, to submit to my insurer after services are rendered.

Yes, I understand and wish to proceed

What insurance do you have?

BCBS, UHC, Medicaid, etc.

Client Preferences

In-person and virtual appointments are only offered on Mondays and/or Saturdays at this time. Please select which day(s) you prefer.

select all that apply

Monday (morning) Monday (afternoon) Saturday (morning)

I prefer to be contacted by:

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Phone Email Secure messaging via SimplePractice

Please share any additional information that will best help your therapist prepare for your chid's evaluation.

Provide specific examples and/or details.

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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.