Blue Sage Pediatric Speech and Language Therapy LLC

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Street address of your desired treatment location

Address of your home, daycare, school, or virtual

City and Zip

Blue Sage Pediatric Speech and Language Therapy is currently able to provide in-person services in the North San Antonio area. Online therapy services are available for other locations via our HIPAA-compliant virtual therapy portal.

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Client's info

Is the client a minor?

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First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Street address of your desired treatment location

Address of your home, daycare, school, or virtual

City and Zip

I understand

Administrative

How did you find out about Blue Sage?

(Word of mouth, Google, Facebook group, referral from another professional, etc.)

Client Preferences

Times available for therapy

Before 3pm After 3pm Flexible

Is there anything else you would like to share?

For example: specific concerns, insurance or payment questions, etc.

Limited to 600 characters

Reason for care

Has your child had speech therapy before?

What are your primary concerns for your child’s communication skills?

Billing & Payment

Blue Sage Pediatric Speech & Language Therapy is currently private pay only, however we can provide superbills for families wishing to use their Out of Network insurance benefits.

I understand

If using Out of Network benefits, please understand that Blue Sage Pediatric Speech and Language Therapy cannot guarantee reimbursement from your insurance provider. Reimbursement differs by insurance provider and is not available with every insurance policy. Some policies do not cover speech therapy services. .

I understand that I am responsible for verifying Out of Network benefits and that reimbursement is not guaranteed by Blue Sage Pediatric Speech and Language Therapy.

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.