Forms required prior to a treatment and/or an evaluation:
• HIPPA Documents, Consent Forms, Financial Statements, Release Forms
• Patient Questionnaire
• Pickup Authorization:
This form will let us know to whom we are authorized to release your child.
• Patient Intake Form:
This form is to be completed by all new patients.
Forms helpful prior to an evaluation:
• Articulation Referral Checklist:
Complete this form if you are concerned about your child's speech sound production.
• Voice Referral Checklist: Pediatric
• Word Finding Difficulties
• Bilingual Language Checklist
• Stuttering Referral Checklist
• Have your child’s teacher(s) complete these forms prior to an assessment!
Brief Initial Classroom Report (all ages):
• Language Referral Checklist – Grades K-1
• Language Referral Checklist – Grades 2-3
• Language Referral Checklist – Grades 4-6
Music Therapy Intake Forms:
• GCMT Audio Visual Release
• GCMT Consent Form
• GCMT HIPAA
• GCMT History and Information
• GCMT Payment for Services
• GCMT Permission to Leave Site
• GCMT Welcome letter