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Today’s Date:
Last name:
First name:
Middle name:
Diagnosis:
Birth Date:
Age:
Sex: MF
Address:
City:
State:
ZIP Code:
Phone:
Alternate Phone:
Email:
Place of Residence:HomeNursing HomeIn-home Hospice CareAssisted Living FacilityAssisted Living FacilityGroup HomeRehabilitation FacilityHospitalHospice
Name of Person Making Referral:
Relationship to Patient:
Type of Referral: Communication AssessmentCommunication TherapyComputer Access AssessmentComputer Access TrainingSpeech & Language AssessmentSpeech & Language Therapy
Name of device:
Name of Products:
Please describe reason for assessment/therapy:
Patient is unable to: (Select all that apply) TalkTalk ClearlyRead/SpellHandwriteWalkUse HandsIdentify Pictures
Unified's No Boundaries Assistive Technology Center does not accept Insurance, Medicare, or Medical Assistance as Forms of Payment.
Fees for services are listed below. Payment may be made on the day of service or, for your convenience, an invoice can be mailed following provision of services:
Augmentative and Alternative Communication Assessment/Assistive Technology/Computer Access Assessment
$350.00 for the initial assessment appointment $100.00 per hour if a second session is warranted
Speech & Language Assessment/Swallowing Evaluation
$300.00 for assessment
Therapy/Training/Presentations
$125.00 per hour
