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Application for Services
Does your child have speech therapy insurance benefits?
Yes
No
If you have speech therapy insurance benefits, what are the co-pays and deductibles?
If you have speech therapy insurance benefits, would paying your insurance co-pays and deductibles be a financial burden?
Yes
No
Why are Rite Care speech therapy services needed?
Name of Child
Child's Date of Birth
Mom's Name
Mom's Cell Phone
Dad's Name
Dad's Cell
Home Phone
Other Phone
Address
City
State
Zip
Referral Source