Waitlist Request

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Waitlist Request

Thank you for your interest in speech and language services. Please note we have a long waiting list at this time. We have recently downsized our practice and only have one full-time provider in San Francisco. We have several providers offering teletherapy. If you think your child is a good candidate for teletherapy, please indicate that on your form below. Teletherapy spots tend to open up more frequently than in-person spots.

You are welcome to join our wait list for any type of service, but note that wait times will be very long for in-person services. We apologize for the inconvenience. To join the wait list, please answer a few questions to help us get a sense of your family's needs so that we can monitor our schedules for openings that will be a good fit for your child. We are in-network with: All Blue Cross & Blue Shield PPO and most EPO plans, Health Net PPO and we are contracted vendors with Kaiser and the Golden Gate Regional Center (GGRC).

Email *

What is your child's name? *

What is your child's current age? *

What is your child's date of birth?

What is your name? *

What is your phone number? *

What is your email address? *

What services are you seeking? (check all that apply)

Evaluation

Therapy

Teletherapy (Virtual/Zoom sessions)

I'm not sure

Other:

What areas are you concerned about? (check all that apply) *

My child isn't talking or has few words

My child seems behind kids his/her age

My child's speech is hard to understand

I can understand my child but some sounds are hard for him/her

My child has a hard time expressing him/herself with words

My child seems to be stuttering

My child has difficulty with feeding and/or swallowing

My child struggles with reading

My child struggles with writing

My child's teacher (or other professional) suggested we get an evaluation

My child's voice seems unusual (hoarse, strained, raspy, unusual pitch)

My child does not seem very interested in interacting/communicating with others

My child likes being with other kids but is having difficulty making friends and playing with others

I sometimes wonder if my child has trouble hearing me

My child doesn't always respond when others talk to him/her

My child has trouble following my directions or answering my questions

I'm concerned about how my child's voice sounds (ex: hoarse, nasal, scratchy, breathy)

I'm not sure

Other:

Required

Has your child had a speech/language evaluation? *

Yes

I'm not sure

(0ptional) What evaluations has your child had? (speech/language, OT, PT, developmental, neuropsych, psychoeducational)What were the results?

Has your child had any previous speech/language therapy? *

Yes

(Optional) Please share any pertinent information about your child's previous speech/language therapy?

(Optional) Is there anything else you would like to add about your reason for seeking speech/language help?

How many health insurance plans is your child covered under? *

None

One

Two

I'm not sure

Which insurance plans cover your child? *

Blue Cross PPO (including Anthem)

Blue Cross EPO

Blue Shield PPO

Blue Cross Blue Shield PPO

Health Net PPO

Kaiser Permanente

United Health Care

Aetna

Cigna

HMO - Brown & Toland

HMO - Hill Physicians

Medi-Cal

I'm not sure

Other:

Required

When would you like to get started? *

As soon as possible

Summer

Flexible

Other:

Please describe your child's general availability (days and times they could attend sessions on a regular basis). *

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