OUR FORMS
Pediatric Feeding & Speech Solutions, PLLC is an out of network provider. You may want to call your insurance company and ask about your "out of network benefits," as you may be able to receive reimbursement for services. After payment of services, you will receive a superbill with billing codes that you can submit to your insurance company to access out of network benefits if they are applicable. Keep in mind that you are able to use funds from Flexible Spending Accounts (FSA) and Health Savings Plans (HSA) for out of network services.
For Any Service:
Feeding, Speech and Language Therapy or Orofacial Myofunctional Disorders
Please download, print, fill out, and bring all applicable forms with you to the appointment, along with your ID.
Feeding / Nutrition Evaluation
Feeding Evaluation:
- Download the forms, print, fill out and bring with you to the appointment.
- Please bring a few preferred or easy foods and a few non-preferred or more difficult foods/ liquids for your child. Please bring any special nipples, bottles, spoon, or cup.
*A feeding evaluation and nutrition evaluation are separate evaluations, although they can be coordinated into one with a team approach from both Kelly and Sonal. Please discuss with Kelly if you would like one or both when you schedule an initial visit.
Nutrition Evaluation:
- For a Nutrition Evaluation please fill in the 3-day Food Journal and Health Intake form, once filled please hit the 'submit' button on the form and they will be automatically sent to Sonal.
Feeding and Nutrition Evaluation Forms
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Feeding Evaluation
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Tube Feeding Form (if applicable)
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Nutrition Evaluation
Speech / Language Evaluation
Download these forms, print, fill out and bring with you to the appointment.
Speech/Language Evaluation Forms
Orofacial Myofunctional Disorders
Download these forms, print, fill out and bring with you to the appointment.