Please complete the necessary documentation depending on age and type of evaluation being received.
Speech & Language Evaluations
Infant/Pediatric
- Communication Evaluation Cover Letter
- Infant/Pediatric (0-5) Speech Pathology Case History Form
- Fluency Case History Attachment
- Cleft Palate/Craniofacial Case History Attachment
Child/Adolescent
- Communication Evaluation Cover Letter
- Child/Adolescent (6+) Speech Pathology Case History Form
- Fluency Case History Attachment
- Cleft Palate/Craniofacial Case History Attachment
Adult
- Communication Evaluation Cover Letter
- Adult Speech–Language Case History Attachment
- Adult Speech Pathology Case History Form
- Fluency Case History Attachment
- Head & Neck Case History Attachment
Swallowing & Feeding Evaluations
Infant/Pediatric
- Swallowing/Feeding Evaluation Cover Letter
- Infant/Pediatric (0-5) Speech Pathology Case History Form
- Pediatric Feeding/Swalllowing Case History Attachment
- Cleft Palate/Craniofacial Case History Attachment
- Pediatric Speech Pathology Case History Form
Child/Adolescent
- Swallowing/Feeding Evaluation Cover Letter
- Child/Adolescent (6+) Speech Pathology Case History Form
- Pediatric Feeding/Swalllowing Case History Attachment
- Cleft Palate/Craniofacial Case History Attachment
- Pediatric Speech Pathology Case History Form
Adult
- Swallowing/Feeding Evaluation Cover Letter
- Adult Speech Pathology Case History Form
- Adult Swallowing Case History Attachment
- Head & Neck Case History Attachment
Voice Evaluations
Infant/Pediatric
- Communication Evaluation Cover Letter
- Infant/Pediatric (0-5) Speech Pathology Case History Form
- Voice Case History Attachment
- Cleft Palate/Craniofacial Case History Attachment
Child/Adolescent
- Communication Evaluation Cover Letter
- Child/Adolescent (6+) Speech Pathology Case History Form
- Voice Case History Attachment
- Cleft Palate/Craniofacial Case History Attachment
Adult
- Communication Evaluation Cover Letter
- Adult Speech Pathology Case History Form
- Voice Case History Attachment
- Head & Neck Case History Attachment
Speech Resonance Evaluations
Infant/Pediatric
- Communication Evaluation Cover Letter
- Infant/Pediatric (0-5) Speech Pathology Case History Form
- Cleft Palate/Craniofacial Case History Attachment
Child/Adolescent
- Communication Evaluation Cover Letter
- Child/Adolescent (6+) Speech Pathology Case History Form
- Cleft Palate/Craniofacial Case History Attachment
Adult
Voice Restoration Evaluations
Adult
- Communication Evaluation Cover Letter
- Adult Speech Pathology Case History Form
- Head & Neck Case History Attachment
Additional Forms
Your doctor may send an insurance referral or written order for above services via fax to (631) 444-4582. If he/she prefers they can complete our Patient Referral Form.
