Feeding Home Program Interest Form
Home visits are 45 minutes in length in your own home with direct consultation available. Payment: Your insurance will be billed for a feeding therapy session and a self pay Home-Based Consultation fee of $100 is applied to each visit. If we do not take your insurance, please inquire about self-pay cost.
Parent / Caregiver Name
Street Address Line 2
State / Province
Postal / Zip Code
I understand that if my home is more than 15 minutes from the WPST clinic, travel fees may apply.
My child has...
speech therapy at WPST
speech therapy at another private practice/clinic
speech therapy at school or through early intervention
no speech therapy services at this time
feeding therapy at WPST
feeding therapy at another private practice/clinic
no feeding therapy services at this time
If your child has received feeding therapy in the past, please list where and when services occurred.
Please briefly describe your child's feeding difficulties.
Please briefly describe your hopes for feeding therapy.
Please provide us with your availability below for the days and time frame for therapy.
Please note that afternoon and evening times may not be readily available and you will be contacted when an appointment becomes available.
Please select the locations where you would like to receive services.
If you selected school or community based please provide the address below.
Please note that school/daycare sessions cannot be guaranteed and must be approved by school officials. Caregivers are expected to contact the child's school to learn more.
Should be Empty: