• Contact Information
  • Your Communication Journey
  • Schedule your introductory call
1. Contact Information

Step 1 of 3

First, let’s get some basic details of who is making this request so we can get in touch for your introductory phone call.
(If service will be for your family member or someone else, we’ll add their information later)

This brief form will take just 2 minutes to complete.

Do you have health insurance?

What is the name of your insurance provider?

Please include your Member ID:

Upload front of the insurance card (Optional):
Upload back of the insurance card (Optional):

Uploading your card is optional, but doing so helps us correctly confirm your insurance information before we speak with you.

Please include your Zip Code:


Great, now let’s find out more about who this service is for.

2. Communication Journey

Step 2 of 3

Almost done!

Are you seeking services for you or someone else?

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State of Residence

Due to regulatory limitations, we are unable to provide services to clients currently located outside the United States.

What issues or concerns are impacting your speech or ability to communicate? (Hold the shift key down when clicking to select all that apply)

Have you ever been diagnosed with COVID?

What are your most important speech therapy goals?

On average, speech therapy is about $130 per week. Are you able to invest that amount? (We do accept HSA and FSA.)

Thanks for sharing all your info! Let’s schedule your introductory phone call.

3. Schedule a call

Step 3 of 3

Schedule Our Introductory Phone Call

Now to schedule a short introductory call where we can get to know you even better.

Choose a day and time that works best for you to chat with a team member:

Please Wait

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    We have received your complimentary consultation form, scheduled on ***. A Great Speech team member will review the completed form on a phone conference with you prior to your scheduled online consultation.

    Your online complimentary consultation will be administered via secure video conference and can be accessed from any laptop or computer with microphone and webcam capabilities.

    A plan of care and payment options will be discussed during your call.

    Sincerely,

    The Great Speech Team

    Tailored, effective, convenient speech therapy that fits around your life.

    How did you hear about us?

    For assistance completing this form, please call us at +1-954-820-7400 between 8am and 6pm EST.