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Speech - Language and Hearing
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Speech Services

  • Swallowing & Feeding
  • Speech & Language
  • Cleft Palate / Speech Resonance
  • Voice
  • Voice Restoration
  • Gender Affirming Voice Services
  • Speech Forms
  1. Patient Care
  2. Speech-Language and Hearing Department
  3. Speech Forms

Speech Forms

For the evaluation appointment scheduled please print and bring with you:  

  1. The appropriate cover letter and review it for details 
  2. The ONE correct case history form for your appointment type and complete fully 

Evaluation Cover Letter

  • Communication evaluation appointments
  • Feeding/swallowing evaluation appointments

Case History Forms
Children: 

  • Feeding/swallowing case history form
  • Speech resonance - cleft palate case history form
  • Voice case history form

Adults: 

  • Swallowing case history form
  • Communication case history form
  • Voice case history
  • Head and Neck Cancer swallowing/communication case history form

Additional Therapy Forms

  • General Therapy agreement
  • Pediatric feeding therapy - caregiver training agreement
  • Understanding your insurance responsibilities
Stony Brook Square Rays
Give us a call
(631) 444-4191
Speech - Language and Hearing
33 Research Way, Ste 4
East Setauket, NY 11733
Hours:
Monday-Friday: 8:30AM-5:00PM
Directions
Hearing Forms 
Speech Forms
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