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Please take a moment to fill out this form.

Client's Full Name

Parent/Guardian Name (required if client is a minor)

Email Address

Phone Number

Client's Date of Birth required

Is the client currently receiving Speech or Occupational Therapy? Required

Yes – Speech Therapy

Yes – Occupational Therapy

If yes, where and how often?

What concerns do you have? What skills would you like us to work on during therapy sessions?

If yes, when was it completed and by whom?

Please email any documents to: admin@speechpathwayssj.com

Would you like to schedule new evaluation or get started with treatment sessions? *Note* We can only start therapy sessions if an evaluation/IEP has already been completed within the last 12 month.

How did you hear about us?

Note: We are a private-pay clinic. We provide superbills that you may submit to your insurance for possible out-of-network reimbursement, depending on your insurance plan. We also accept the Step Up for Students scholarship (EMA) and the Down Syndrome Association of Jacksonville scholarship (DSAJ).

Acceptable forms of payment:

Credit card, HSA card, cash, check
Step Up / FES-UA / Scholarship
Down Syndrome Association of Jacksonville

Please check this box to indicate that you have read the information above and acknowledge our private-pay policy.

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CONTACT US

admin@speechpathwayssj.com

12627 San Jose Blvd, Jax 32223, unit 803

at Julington Creek Business Park

Get Started!

Please email any documents to: admin@speechpathwayssj.com

Note: We are a private-pay clinic. We provide superbills that you may submit to your insurance for possible out-of-network reimbursement, depending on your insurance plan. We also accept the Step Up for Students scholarship (EMA) and the Down Syndrome Association of Jacksonville scholarship (DSAJ).

Acceptable forms of payment:

Credit card, HSA card, cash, check

Step Up / FES-UA / Scholarship

Down Syndrome Association of Jacksonville

CONTACT US