New Client Readiness & Intake Questionnaire

This questionnaire helps us determine whether Salt & Light is the best fit for your needs and allows us to guide you toward the appropriate next steps for care.

We are in network with BCBS, ALL Kids, & traditional Medicare.

We do not accept Medicaid.

Client name*

Client's Birthday *

Month

Day

Year

Parent/guardian name*

Email*

Phone*

How did you hear about us? *

We offer the following services at Salt & Light for both our pediatric and adult clients. What service/services are you interested in? *

Speech sound/articulation therapy

Language therapy

Myofunctional therapy

Voice therapy

Swallowing difficulty

Oral habit elimination

Unsure/need guidance

Other (please briefly describe)

Short answer

Readiness- please check all statements you agree with:*

I understand therapy is a process and not a quick fix

I can commit to consistent weekly appointments

I am willing to complete home practice as recommended

I understand progress depends on follow-through outside sessions

I value education and collaboration as part of care

Which best describes your availability?*

Some services are eligible for insurance reimbursement when medically necessary. Other services are private pay or package-based and may not be reimbursed. Coverage cannot typically be determined until an evaluation is completed.*

I understand and am open to learning more

I need insurance-covered services only

I’m not sure yet

Please describe your current concerns and include any previous speech, feeding, or myofunctional therapy services your child (or you) have received.*

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Speech Therapy, Language Therapy, & Myofunctional Therapies

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Contact Salt & Light

Phone: 205-582-7717

Fax: 205-855-3017

Email: hello@saltandlight-slp.com

Address: 400 Vestavia Pkwy, Suite 135

Vestavia Hills, AL 35216

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