Infant Intake form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Infant Intake form

Thank you for interest in Lingua Speech, Swallow, and Voice Services. We are proud to serve NEPA, Lehigh Valley, and Bucks County. Please answer the following questions and you will receive an email connecting you with your provider once it is complete!

Email *

How would you like to receive your services?

In office: 135 S Main Street Pittston, PA ($100.00)

In office: 311 Wyoming Avenue, Wyoming, PA ($100.00)

In Home: Lehigh Valley and Bucks County ($125.00)

I am in NEPA but would like in home ... is anyone available?? ($125.00)

Teletherapy ($85.00)

Other:

Would you like to do a prepaid bundle discount? (in office and teletherapy only )

Not at this time

I will start with my evaluation and then see which bundles I need

Yes, 6 session bundle ($500 in office/ $460 for teletherapy)

Yes, 5 session bundle ($425 in office/ $400 for teletherapy)

Yes, 4 session bundle ($375 in office/ $330 for teletherapy)

Yes, 3 session bundle ( $275.00 in office/240 for teletherapy)

Yes, 2 session bundle ($190.00 in office/ 165.00 for teletherapy)

Would you like to do a subscription service? This an upfront payment that allows a month of sessions (4) plus ongoing access to your provide via text/email. (Available for in office, teletherapy, and in home)

Not at this time

I will start with my evaluation and then consider!

Yes, 1 month subscription (425.00)

Yes, 2 month subscription ( 750.00)

Times/Days that absolutely do not work with your schedule or time/days preferred to have a session.

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms