Branching Tree Speech Therapy, PC Send Message

Who would be receiving care?

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Reason for care
(e.i. G-tube, cast, wheelchair, AAC device, brace)
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If yes, please provide the frequency of services received, date(s) of evaluation, and any recommendations given.
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Please check all that apply:
If yes, please list the diagnosis names and their corresponding ICD-10 codes (if known)
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Other concerns
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Administrative
Enter how you were referred to our services
Billing & Payment
How do you plan to pay?
Upload a photo of your insurance card
Disclaimer: This information must be provided in order to verify eligibility and benefits.
(Full Name, Sex, Date of Birth, Home Address) Disclaimer: This information must be provided in order to verify eligibility and benefits.
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If yes, please provide the primary policy holder and Insurance information
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Client Preferences

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.