Referral Form

Unified Community Connections
No Boundaries Assistive Technology Center

    Patient Information

    Reason for Referral

    Physician Information

    Insurance Information
    Please note: Unified’s No Boundaries Assistive Technology Center does not accept Insurance, Medicare, or Medical Assistance as forms of payment for assessments, therapy, or training. Information below should be completed for Patients receiving a Communication Device Assessment to assist in procurement of the communication device:

    Payment Information
    Fee Schedule

    Augmentative and Alternative Communication Assessment/Assistive Technology/Computer Access Assessment $300.00 for the initial assessment appointment
    $100.00 per hour if a second session is warranted
    Speech & Language Assessment $300.00 for assessment
    Augmentative and Alternative Communication Set-up/Therapy/Training $125.00 per hour
    Assistive Technology/Computer Access Set-up/Therapy/Training $125.00 per hour
    Speech & Language Therapy $125.00 per hour
    Presentations/Training $125.00 per hour (does not include the cost of any requested presentation materials)
    Travel fees for any service occurring outside of Unified’s main office $40.00 per hour