Doctor & Practitioner Referrals

Thank you for referring us to your patient / student. Feel free to fill out the form below or call us at (360) 841-8096

Referral Information

Referring Partner Name(Required)

Affiliated Clinic(Required)

Referring Provider's Phone Number(Required)

Referring Provider's Fax Number and/or Email(Required)

Patient Information

Patient's Name(Required)

Patient's Date of Birth(Required)

Month

Day

Year

Parent / Guardian Name

Best Contact Number(Required)

Best Email Address

Potential Diagnosis of Patient(Required)

M26.59 – Other Dentofacial

Q38.1 – Ankyloglossia/ Tongue Tie

R63.3 – Feeding Difficulties

R13.11 – Dysphagia, oral phase

R47.89 – Other Speed Disturbance

F80.0 – Articulation Disorder

F84.0 – Autism Spectrum Disorder

F80.1 – Expressive Language Disorder

F802 – Mixed Expressive – Receptive Language Disorder

Unknown

Other

Other Diagnosis

Additional Notes

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Speech and Language Therapy for children and adults in Woodland, Longview, Kelso, and Vancouver, WA. Telehealth only options available for Oregon clients.

Phone : (360) 841-8096

Fax : (360) 326-1599

1900 Belmont Loop
Woodland, WA 98674

Doctor, dental, practitioner referrals.
We are thankful for your referral. Click the button to refer or fax a referral to
(360) 326-1599

Referrals

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