Form Instructions

In preparation for your child's speech therapy evaluation your speech therapist requests that you download all the forms below and return them along with a copy of your child's latest school ARD meeting record and school speech therapy goals and progress report via fax to (480) 287-8474.  Do not email your completed forms as email is not HIPPA compliant. 

 

  • Pediatric Questionnaire Form-  This form captures all clinical information about your child's development and academic performance.
  • Authorization for Speech Language Treatment-  This form gives us permission to work with your child.
  • Speech Inspiration Registration Form-  This form captures your insurance and billing information.  Please attach a copy of your insurance card when submitting this form.
  •  HIPPA Privacy Notice -  Please read our commitment to your privacy.  This form is your copy to keep for your records. 
  • Notice of Privacy Practices Acknowledgment Form-  Sign and return this form once you have read the HIPPA Privacy Notice.
  • Speech Inspiration Referral Form- This form is provided for your convenience for you to take to your child's physician if a physician order is required by your insurance plan.
  • Welcome to Speech Inspiration Policy-  This attachment contains all billing, scheduling and payment policies for Speech Inspiration.  This is your copy to keep.
  • Authorization to Obtain Information- This form allows for the child's teacher(s) and school speech-language pathologist or other provider to provide input to Speech Inspiration on your child's performance.
  • Release of Information-  This form is for you to list the names and contacts of whom (e.g. physician, school speech-language pathologist, teacher)  should receive your child's evaluation record once completed.

Downloads

Speech Inspiration Pediatric Questionnaire Form (pdf)

Download

Speech Inspiration Authorization for Speech Language Treatment (pdf)

Download

Speech Inspiration Registration Form (pdf)

Download

Speech Inspiration HIPPA Privacy Notice (pdf)

Download

Notice of Privacy Practices Acknowledgment Form (pdf)

Download

Speech Inspiration Referral Form (pdf)

Download

Welcome to Speech Inspiration Pediatric Policy 2018 (pdf)

Download

Speech Inspiration Authorization to Obtain Information (pdf)

Download

Speech Inspiration Release of Information (pdf)

Download