Waiting List Form

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Waiting List Form

Sarah Lockhart Speech Therapy

850 Siskiyou Blvd STE 9

Ashland OR 97520

(541) 708-3940

sarah@sarahlockhartspeech.com

Email *

Does your child receive ABA therapy (Applied Behavioral Analysis) or are you considering starting?

Yes

Clear selection

Do you have insurance we accept?

Providence

Regence

Moda

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Parent Name (first and last)
*

Student/Child's Name:
*

Student/Child's Date of Birth:
*

YYYY

Communication concern (choose all that apply): *

Autism

Gestalt Language Processor

AAC Alternative and Augmentative Communication

Expressive and Receptive Language

Speech Sounds/Articulation

Nonspeaking or Minimally Speaking

Social Communication

Other:

Required

For your information, we don't see students for: stuttering/fluency, selective mutism; so we recommend you get on waiting lists elsewhere for those concerns

I understand

Clear selection

I understand that daytime appointments have a waiting list of 2-4 months, and after school appointments have a waiting list of 9-12 months.
*

I am available 9am-2pm for an appointment

I understand, I will wait for an afterschool appointment (9+ months)

Has your child (or you) had a current speech-language evaluation in the past six months to one year? *

Yes

What are your communication goals and why did you seek out services at this clinic?
*

How did you hear about this clinic?
*

What are your child's strengths and interests?

List any prior services (school and/or private clinic)

These are private pay rates. We can provide you with a Superbill if needed for you to submit to insurance.

Services are provided at the following fee schedule:

$300 Speech-Language Assessment with formal report and treatment plan (45-60 minutes)

$200 Informal Speech-Language Assessment without formal report, JUST treatment plan (30-45 minutes)

$166 60 minute therapy session (55 minute session, 5 minute notes/parent contact)

$125 45 minute therapy session (40 minute session, 5 minute notes/ parent contact)

$100 30 minute therapy session (25 minute session, 5 minute notes/parent contact)

$125/hr attendance at IEP meetings and school observations

$125/hr consultations with providers or parents

I understand and will be paying out of pocket

Clear selection

If you have Regence, Providence or Moda insurance, enter your plan name, ID number and group number, and employer on your card below

Please check the boxes below to show us you understand our process!

I am aware you have a waiting list for all speech-language appointments

I am aware that I will be contacted via email with ANY openings that match my selected availability

I am aware that I will have the opportunity to speak with a speech-language pathologist IF and WHEN an appointment becomes available

I am aware that I may be on the waitlist for as short as a day or as long as several months.

Required

I understand I'm expected to get on multiple waiting lists. At this time I am unaware of anywhere (besides Asante) who takes Moda. I am unaware of any options (Besides Asante and Julie Spencer) who take Jackson Care Connect. I am not including email addresses for providers who are full and not taking referrals. Options:

Julie Spencer (Jackson Care Connect, takes most private plans except Moda, ages 4+) currently full

Rachel Levine (speech sounds over age 3 only, accepts Providence and Regence) rachel@levinespeechtherapy.com

Carrie Eskenazi (Providence, Regence, Pacific Source) carriespeechpath@gmail.com

Chrissy Austin (Autism Private Pay groups), currently full

Angela Barber (Regence) angela@ashlandspeech.com

Laura Allred (part time, Regence & Providence), currently full

Asante - currently full and not accepting a waiting list

Yes

Full Legal Name of Person Signing Form
*

Your Email
*

Your Phone Number
*

Date of Form Completion
*

YYYY

A copy of your responses will be emailed to the address you provided.

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