Early Intervention Speech-Language Pathology Services

Please contact our office manager at [email protected] with any questions

New Patient Referral Form

Referral form for new patients. 

Please fill out and send our referral form via email or fax to [email protected] or 

850-391-4178.

Referral Form

Child Intake Packet

Child intake packet includes: child history form, cancellation policy, privacy policy, authorization to release records, consent for student clinician and therapy scheduling preferences forms.

Child Intake Packet

Infant intake packet

Infant intake packet includes: infant history form, cancellation policy, privacy policy, authorization to release records, and consent for student clinician forms.


Infant Intake Packet

Child History Form

Form used to gather information about your child's history 

Child History Form

Infant History Form

Form used to gather information about your baby's history 

Infant History Form

Privacy Policy

Notice of our privacy policy for our practice 

Privacy Policy

Cancellation Policy

Notice of our cancellation policy for our practice

Cancellation Policy

Records Release

Authorization to release records form

Release Records Auth

Client CC on File

Client credit card on file agreement

Client CC on File

Consent for Student

Consent or decline for SLP student clinician to evaluate/treat

Consent for Student

Schedule Preference

Client therapy scheduling preferences form

Scheduling Preferences