APPLICATION FOR CLINIC SERVICES 2026

1. Click ‘Get Form’ to open the APPLICATION FOR CLINIC SERVICES in the editor.
2. Begin by entering the client's first and last name, date of birth, and age in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Indicate the gender of the client and provide contact details for a person regarding this application. If you are an adult applying for yourself, complete that section; otherwise, fill out the minor's section.
4. Fill in the address fields, including city, state, and zip code. Select preferred phone numbers and email addresses for communication.
5. In the speech and language information section, describe your concerns about the client's communication abilities. Be detailed to help clinicians understand specific needs.
6. If applicable, provide details about previous evaluations or treatments. Attach any necessary supporting documents like IEPs or medical records using our platform’s upload feature.
7. Review all entered information for completeness before submitting via email, fax, mail, or in person as instructed at the end of the form.

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