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Request a Consultation

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About Us
Testimonials
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Unique Speech Retreat
Contact Us

Consultation Request

Complimentary phone consultations are offered to discuss your questions and concerns in order to determine if you or your child would benefit from a comprehensive evaluation. During the consultation, we have the opportunity to review documents and discuss the intake process if speech therapy may be determined to be appropriate.

Parent's Name *

First

Last

Parent's Email Address *

Parent's Phone Number *

Patient's Name *

First

Last

Patient's Date of Birth *

Patient's Gender *

Male
Female

I'm interested in *

Speech Therapy Services
Unique Speech Retreat /Parent free Events for Children
Both
Other

Please select the area/areas of your concerns? *

Articulation (Speech/ Producing sounds)
Fluency (Stuttering/ Rate of Speech)
Language (Expressive or Receptive)
Pragmatic Language (Social Communication)
Pediatric Feeding/ Swallowing
Adult Dysphagia
Dementia
Aphasia
Stroke
Other

How do you or your child communicate? *

Oral communication
Vocalizations
Communication device

Has your child been evaluated by an ear, nose and throat (ENT) doctor or had a hearing screening? *

Yes
No

Primary Care Practice/Physician *

Method of Payment *

Private Pay
Insurance
SSES

Method of Payment (copy) *

Blue Cross Blue Shield
Medicare
Medicaid
Tricare *Certified
Other

Questions/Additional Concerns for Unique Speech Techniques? *

Unique Speech Techniques is a private practice that prioritizes building relationships and providing quality speech therapy services to the pediatric and adult population. We offer tele-health in TX, MS, and GA and in-office visits in Mansfield, TX.

© Unique Speech Techniques, PLLC.

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Home
About Us
Testimonials
Services
Unique Speech Retreat
Contact Us

Request a Consultation

Home
About Us
Testimonials
Services
Unique Speech Retreat
Contact Us