Forms
In preparation for your first appointment at Central Speech & Language Clinic, Inc., please print out and complete the first four forms. The final forms are for your records.
- New Client Information
- If you have Blue Cross Blue Shield PPO or Aetna (PPO, HMO, POS), please fill out this form: New Client Info - Insurance
- If you have a different insurance plan than those above, do not have insurance that will cover these services, or do not have health insurance, please fill out this form: New Client Info - Self Pay
- Case History Form
- If the appointment is with the Fluency Center for a child, please fill out this form: Fluency Case History - Children
- If the appointment is with the Fluency Center for an adult, please fill out this form: Fluency Case History - Adults
- For all other appointments, please fill out this form: Case History Form
- Financial Policy
- For all appointments, please fill out this form: Financial Policy
- Consent for Exchange of Info
- If you would like your speech-language pathologist to share information with another party, please fill out this form: Authorization to Exchange Information
- For Your Records
Once you have completed all the necessary forms, please return them to us by mail or fax in advance, or bring them along to your first appointment.
Central Speech & Language Clinic, Inc.
4160 IL Route 83, Suite 101
Long Grove, IL 60047
Phone: 847-821-1237
Fax: 847-276-2743
Not sure what else you should do to prepare for your first appointment? Check here for an answer to that question.
If you are having difficulty downloading these forms, please contact your speech-language pathologist and ask her to send them to you via e-mail.
If you have any other questions, feel free to contact Jen Malone Priest at: 847-821-1237 x3 or .
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