Speech & Language Therapy Enrollment Application

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URL

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Personal Information

Child's Name(Required)

Child's Date Of Birth(Required)

MM slash DD slash YYYY

Parent(s)/Guardian Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent 1 Phone Number(Required)

Parent 1 Email(Required)

Parent 2 Phone Number(Required)

Parent 2 Email(Required)

Center location choice for services(Required)

Insurance Information

Primary Insurance Company(Required)

Policy Holder's Name(Required)

Relation To Child(Required)

Policy Holder's Date Of Birth(Required)

MM slash DD slash YYYY

Occupation/Employer(Required)

Enrollee ID/Group Number(Required)

Education Information

Skip to the next section if your child is not in school yet.

Name of School(Required)

Grade(Required)

Classroom Description(Required)

Most recent IEP/IFSP date(Required)

Additional Services

Please list any services your child currently receives. (i.e. speech, OT, etc.) Include provider name, types of service, duration of service, and frequency(Required)

Please list any any evaluations that have been conducted with your child (speech/OT/PT/Psych/Behavioral)

Hearing Status (check box/boxes)(Required)

frequent ear infections/middle ear fluid

Hearing Loss

Ear Tubes

Feeding history (check box/boxes)(Required)

difficulty breast or bottle feeding

choking on liquids

difficulty chewing solids

poor weight gain

reflux

selective/picky eating

swallow study conducted

feeding tube placed

feeding tube removed

Medical & Behavioral Health History

Approximate age your child babbled(Required)

Approximate age your child said first word(Required)

Approximate age your child produced sentences(Required)

Approximate age your child combined two words(Required)

Please indicate if any of the following variables that could affect your child's treatment apply to your family (historically or currently). If yes, include brief explanation(Required)

If any of the above are marked please provide brief explanation.

How has your child's overall health been?(Required)

Please list your child's current medications (both prescription and over-the-counter) and the conditions being treated(Required)

Please describe your child's food and medication allergies, if any(Required)

What speech concerns do you have for your child? (sound production, motor control, fluency)(Required)

What interests or excites your child, what are his strengths? what frustrates her?(Required)

Please explain your speech-language concerns and hopes for intervention?

Emergency Contact Information: Name, Relation, Phone(Required)

Service Confirmation(Required)

I am aware that Behavioral Analysts of West Michigan is an in-center provider. I am aware of the business hours for the organization and the services provided.

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File Upload

FRONT of Insurance Card

Max. file size: 1 GB.

BACK of Insurance Card

Max. file size: 1 GB.

Speech & Language Therapy Enrollment Application

Personal Information

Insurance Information

Education Information

Additional Services

Medical & Behavioral Health History

File Upload

Interested In Enrolling?

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