FORMS AND POLICIES
SPEECH and LANGUAGE THERAPY Cancellation Policy:
A 24-hour notification is required for cancellation of a therapy session.
If rescheduling for that week is not feasible, a $35 charge will be given.
Private Pay & Out-of-Network Billing Options
Out-of-Network Insurance Carriers
If we are out-of-network with your insurance company, full payment of service is due the day of service. We will submit a claim on your behalf as a courtesy (requesting our clinic to complete portions of forms from your company to repay you later is $85). Depending on your insurance plan, out-of-network benefits may be payable after your deductible is met. Some carriers will reimburse you directly, while others will reimburse the clinic. If the clinic is reimbursed the amount will be credited to your account and future payments for services will be adjusted accordingly. Written reports will be provided upon request from your insurance company as needed.
Private Pay Speech-Language Therapy
Initial Evaluation Fee is $400.00 if parents intend to receive follow up services if the child qualifies. Those needing an evaluation only, without intent to be served by Shelli's Speech, Language, & Reading, will be charged an evaluation fee of $500. The initial evaluation fee includes an evaluation and a written report. If further consultation is needed for recommendations made, a fee of $125.00 will provide a one-hour consultation of the written report/treatment goals. Note that a consultation without the patient present the majority of the time is not covered by insurance. Private pay Speech-Language therapy treatment sessions are discounted to $95.00 per hour, and Half Hour Discount Price is $40.00 per session. Orton-Gillingham/Structured Literacy-only therapy is discounted to $85 per session. Two-three sessions/week, plus home assignments, are required for dyslexia-based services. Additional services provided include attending an IEP meeting ($125.00) and performing school observations, consultation or home observations for up to 1½ hours ($150.00). All payments are due at time of billing.
Please note we may not be able to work with some policies (in-network or out-of-network) that use substantially lower than market standards as 'payment' for services. Please be aware of deductible and co-pays, and of need to make payments for any amounts not paid by your insurance.
SPEECH-LANGUAGE CLUBS
At Prairie Creek Inn Sunset Barn or
via secure online platform!!
REGISTRATION FORM
Shelli A. Cook, MS, L-CCC-SLP
Speech, Language, and Reading
Featuring all kinds of Fun, Multi-Sensory Activities and the Science of Reading (IDA), and, of course, a Prize Store!!
Student name__________________________________
Age__________________________________________
Parent name(s) _____________________________________________
Email________________________________________
Emergency contact # ____________________________
Allergies (for prize store)_______________________________________
In order for your child to be successful at speech camp, he/she must meet certain expectations.
Your child must be able to:
1. attend for near group or age-appropriate amount of time
2. follow directions and cooperate with adults and peers
3. cooperate and work with others
Non-compliant behaviors will significantly reduce the amount of progress as addressing behaviors takes time away from working on speech goals. Children who exhibit non-compliant behaviors may be dismissed from camp and a prorated refund will be given. * Special considerations may be made on a case-by-case basis notified prior to the start of camp.
_TELEPRACTICE CONSENT (if applicable) - I voluntarily consent to telepractice for the chosen camp session(s), which may include routine assessment and/or treatment by this licensed, certified speech-language pathologist. I understand that an adult caregiver is to be available at all times to assist with technology, materials, and behavior____(initial)
-I hereby give my child permission to participate in the Speech-Language Camp with Shelli's Speech & Language. I also agree to hold Shelli's Services harmless for any and all liability incurred as a result of my child’s participation.
I understand that consistent attendance at camp will allow for the most progress and I will make every attempt to have my child attend the scheduled camp dates.
_____________________________________________ Date: __________________
CONSENT TO PARTICIPATE & HOLD HARMLESS AGREEMENT:
I,____________________________________, parent/guardian, do hereby grant permission for the above named child to participate in this event/activity. In consideration of my child’s participation, I agree to indemnify and hold harmless Shelli Cook from any and all liability or claims brought by anyone, including, but not limited to claims related to use of the venue.
Signature______________________________________
Date___________________________
Payments may be made by debit card via SquareUp email Invoice sent to you. Checks or cash payments upon request.