West Michigan Local Therapy Resource Guide: Submission Form

It would be great to include you in the West Michigan Local Therapy Resource Guide!

This guide will go out to all participants in area Screening Events and individual evaluations/screenings offered by High 5 Speech Therapy. It will also be shared publicly on the High 5 Speech Therapy website.

Sign in to Google to save your progress. Learn more

Business Name or Solo Practioner’s Name (write it as you want it listed in the Resource Guide)

 *
Website Address
Phone Number You Want Listed in Resource Guide
 *
Please list all services your business offers (e.g. speech therapy, OT, PT, ABA, hippotherapy, tutoring etc.)
 *
Does your practice do home or office visits? *
Required
In what town(s) do you provide services? 
 *
What are your hours OR when does your business generally see clients?
 *
What ages does your business work with? 
 *
Do you bill insurance?
 *
If yes, what insurance plans/companies do you work with? 
 *
List any areas of specialty or expertise you would like shared in the Resource Guide
 *
If you would like to share any misc. info with families about your business in the Resource Guide, list it here
 *
The info below is for office use only and will not be publicly shared.
Contact person for your business
 *
Direct Phone Number
 *
Email Address
 *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Emily Goudreault. Report Abuse
Google Forms