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


    $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