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INTAKE FORMS

Download our new patient intake forms

CASE HISTORY FORM

This form is to give us a background on your medical history relating to your speech or swallowing  difficulties.

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GENERAL INTAKE FORM

This is your general information: name, address, insurance.

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MEDICAL RECORDS RELEASE FORM

This form allows us to share your medical records with your doctors and therapists.

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HIPPA PRIVACY POLICY FORM

This form describes  how medical information about you may be used and disclosed, and how you can get access to this information. 

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TELETHERAPY 
CONSENT FORM

This form gives us authorization to treat you over online video call platform. This is known as teletherapy.

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SUPREME SPEECH POLICY FORM

This outlines our cancelation and no-show policy.​

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MEDICARE ELIGIBILITY FORM

This form is to determine your eligibility for receiving Medicare coverage for treatments.  If you are currently receiving services via Medicare Part A, you will not qualify for Part B services.

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GENERAL CONSENT FORM

This form authorizes Supreme Speech to evaluate and treat you.

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