Name of Primary Insured Person (You or Spouse's Name, not child)*
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First Name
Last Name
Email
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Primary Insured Date of Birth*
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Insurance Company
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Insurance Plan
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Policy Number / Member ID
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Group Number
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Insurance Phone Number
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(###)
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Insurance Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Patient's relationship to the Primary Policy Holder
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First Name (Caregiver / Parent)
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Last Name
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Mobile Number
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Home Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Patient's Name
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First Name
Last Name
Patient's Date of Birth
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Gender
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Primary Language
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Is an interpreter required for a Speakeasy Therapy session? Please note: If required an interpreter will need to be arranged by the client or through support coordination.
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Do you or the patient have a pre-existing relationship with SpeakEasy Therapy, P.C.
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Has the patient been assessed for speech therapy or occupational therapy within the last year.
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Are you a new, existing, or return patient
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Does the patient have a diagnosis or disability
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If yes, what is the diagnosis or disability? Example:Cerebal Palsy, Autism, Cleft
Does the client receive any other services? Example: OT or ABA (Applied Behavioral Analysis)
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Name of ABA / OT provider or None
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Choose the main concern (s)
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When did you first notice difficulties
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What area (s) does the patient need speech pathology support
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Please use this space to let us know of any concerns that would help us to prepare for your first appointment
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The initial assessment requires an In-clinic visit. Are you able to come in person to our 9 Mott Avenue (not street) Norwalk CT 06850? Future sessions for your convenience may be scheduled as telehealth if the patient qualifies.
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How did you hear about SpeakEasy Therapy
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