Submit online from any device!

1 | Referral
Click HERE for the REFERRAL FORM to begin services if available. 

2 | Patient Intake
Click HERE for the PATIENT INTAKE FORM to complete prior to your child's first appointment. 

3 | Credit Card Authorization 
Click HERE for the CREDIT CARD AUTHORIZATION FORM to pay for services when applicable.

4 | Telepractice Consent 
Click HERE for the TELEPRACTICE CONSENT FORM to allow virtual visits when permitted.

5 | Insurance Waiver 
Click HERE for the INSURANCE WAIVER FORM to deny consent to bill insurance. 



Contact Kristen Dietrich at 843-810-9198 or by email at records@secure.dietrichspeech.com with any questions.