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Provider Referral Form
Partner with Us
Thank you for referring your patient to Salt & Light Speech-Language Resources.
We value collaboration with our community providers to ensure every client receives the comprehensive support they need. Please complete the form below so our team can reach out to the family and begin the intake process.
Note: This referral form is intended for professional use. If you are a client or parent seeking services, please book your initial consultation call here instead.
All information submitted will remain confidential and used solely for care coordination.
If you would like to provide additional documentation or have files that need to be transmitted securely, you can fax or email those to us:
Fax: 205-855-3017
Email: hello@saltandlight-slp.com
By submitting this referral, I confirm that I am a licensed healthcare provider or authorized representative referring this patient for evaluation and treatment services with Salt & Light Speech-Language Resources.
Confidentiality Notice: This information is intended only for care coordination purposes. Please do not include unnecessary personal health information. If you prefer to share sensitive data securely, please contact our office for our HIPAA-secure upload link or fax number.