Freedom of Speechies, PLLC.

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

Sex at birth

For insurance verification

State

Select the state you live in

Current Zip Code

For in-person clients, this helps us confirm service availability in your area.

Reason for care

What is the reason for seeking care?

Tell us briefly about your child's communication concerns, goals, or what brought you to us today.

What kind of care is being sought?

Select all that apply.

Speech & Language Evaluation Ongoing Speech Therapy Parent Coaching / Consultation Unsure (would like guidance) Adult Speech Therapy Corporate/Workplace Communication Training

Administrative

Inquiry reason

This helps us direct your inquiry to the right person as quickly as possible.

Referral source

Enter how you were referred to our services

Client Preferences

Preferred appointment times

Select all that apply. We'll do our best to accommodate your schedule.

Morning Afternoon Evening Weekend Flexible/No preference

Preferred modality

In-person sessions are conducted at your home, ABA center, or daycare. Travel is included in your plan; no extra fees.

Is there anything that the practitioner needs to know?

For example: scheduling needs, sensory considerations, communication preferences, or anything that would help us prepare for your first appointment.

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.