Patient Intake Forms

New Patient Request Form Patient Intake Form Alternative Downloadable Forms

New Patient Request Form

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Patient Intake Form

Alternative Downloadable Forms

We would prefer that patients use the online form on this page, but we also provide some forms that can be downloaded, printed and completed.

Print and review our Office Polices.
Read this document and bring a signed copy of the agreement of page 4.

Read the HIPPA Privacy Rights.

Print and sign the downloadable HIPPA Privacy Acknowledgement Form. Bring this with you to your first appointment.

Print and sign the downloadable Educational and Promotional Release of Information form.

Since we may be attempting to utilize your insurance benefits, submit the online Insurance information form. We will use that to determine your benefits for orofacial, myofunctional, speech, and language services. Do this as soon as possible ahead of your first visit.

Please bring your insurance card to this first appointment.

If you have any medical, therapeutic and academic information that would facilitate our appointment please bring it along with you!

Parents

If you are a parent, complete the downloadable Child Intake Form, downloadable Child Information Release Consent form and downloadable Pediatric Sleep Airway Survey form.

Download, print and fill out each form, and bring a copy to our first appointment.

Adults

If you are an adult, complete the downloadable Adult Intake Form, downloadable Adult Information Release Consent form and downloadable Adult Sleep Airway Survey form.
Download, print and fill out each form, and bring a copy to our first appointment.

Referral Forms

For referrals, please complete one of the two online forms below:

General Referral Form (online form)
Orofacial Myology Referral Form (online form)

The Practice Location of our office in Seattle/Mercer Island is listed at the bottom right of the Home page. Parking is available directly on the street/adjacent to the Northgate Park Professional Building.

Help is available!

Laura Smith, licensed speech-language pathologist and certified orofacial myologist, is specially trained to assist children and adults in overcoming their communication challenges. Her holistic approach takes into account the person as well as the problem.

Telepractice appointments are available, where clients can receive consultation and therapy services using online tools. In-person appointments upon request.

Contact us for more information or to make an appointment.