SpeechWorks/BreatheWorks Teacher/Clinician Referral
Multidisciplinary Team (SLP, OT, BodyWork) Lake Oswego/NE Portland Locations, 971-346-0355, info@breatheworks.com
Referring Provider
Name
School/Practice
Date of Referral
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Month
-
Day
Year
Date
Client Name
First Name
Last Name
Preferred Pronouns
Patient Date of Birth
-
Month
-
Day
Year
Date
Patient Contact Number
Please enter a valid phone number.
Email (if accessable)
example@example.com
Caregiver/Parent Name (if applicable)
Teacher Name and Email Address (if applicable)
Signs and Symptoms of Oromyofunctional Disorder
Mouth Breathing
Disrupted Sleep
Grinding/Clenching
Poor Posture
Noxious Oral Habits
Pain in Head/Neck/Shoulders/Back
Swallowing Difficulties
Speech Sound Disorder
Voice Differences
Fluency Disruption
Feeding and/or Swallowing Issues
Expressive Language Delay/Disorder
Receptive Language Delay/Disorder
Social Communication Disorder
Autism Spectrum Disorder
Learning Disability Suspected/Diagnosed
Picky Eating Habits
ADHD/ADD
Anxiety/Anxious
Depression
Digestive Issues
Dental Malocclusion
Tongue Tie Suspected
Lip Tie Suspected
Gross Motor Delay
Fine Motor Delay
Sensory Processing Issues
Other
Notes and/or Current/Upcoming Treatment Plan
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Billing Information
BreatheWorks is in-network with CareOregon*, Cigna, First Choice Health, Health Net , Moda Health, MultiPlan, PacificSource Commercial, PacificSource Community Solutions, Providence, Regence Blue Cross Blue Shield, TriWest Healthcare Alliance, Trillium Health. Other medical health plans they will submit out of network claims.
Contact
Thank you for your trust in our care. We strive for best practices and like to coordinate care and communicate efficiently with each patients care team. Please feel free to leave your preferred method of communication below.
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