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New Patients Forms

Please complete the intake form for the service(s) you are interested in pursuing for your child! In addition, please send the additional documentation needed to our fax at 504-218-5317 or email info@lopez-addison.com We will reach out to you to schedule your child's evaluation once all documentation is received. Thank you!

Credit Card Authorization Form

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Speech Therapist
Learning the ABCs

Pediatrics Speech Therapy

Please also send a referral for speech therapy from your child's pediatrician

Pediatrics Feeding Therapy

Please also send a referral for speech therapy from your child's pediatrician

Medical Consultation

Adult Speech Therapy

Please also send a Referral for speech therapy from your primary doctor.

Privacy

This privacy policy sets out how Lopez Addison Therapy, LLC uses and protects any information that you provide. Lopez Addison Therapy, LLC is devoted  to  ensuring  that your  privacy is protected.  Should  we  ask  you  to provide certain information by which you can be identified when accessing your account  information, you can be assured  that such information will only be used in accordance  with this privacy statement.  Lopez Addison Therapy, LLC has a  firm policy of protecting the confidentiality and security of information  that  we  collect  from  our  clients.  We  do  not  share  your  non‐public  personal information with unaffiliated third parties. Information is only shared with your consent  except  for  the  specific  purposes  below,  in  accordance  with  all  applicable  laws.  Please read this policy carefully.   It gives you important information about how we handle your  personal information.  Lopez Addison Therapy, LLC reserves the right to change this policy at any time. USE OF INFORMATION - We limit the collection and use of non-public personal information to the minimum we  believe is necessary to deliver superior service to you.   Correspondences can include advising you about our services and events happening at Lopez Addison Therapy, LLC.   WHAT WE COLLECT - We  obtain  most  non‐public  personal  information  directly  from  you, by telephone or electronically.  We may obtain the following information:  First name, last name, email address, home address, telephone numbers and insurance information. WHAT WE DO WITH THE INFORMATION WE GATHER - We  request  this  information  in order to provide services and so you will be informed of our services and programs.

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