Patient Information and Consent Form

Thank you for your interest in Synaptic Pediatric Therapies! Our commitment is to ensure your child receives premium speech and occupational therapy with our licensed Speech and Occupational Therapists. We promise to show the same compassion to your child as you would, and commit to help improve his speech and occupational skills. 
Please fill in the following information to the best of your ability, and an administrator will reach out to you to set up an initial evaluation within 24-48 hours. Alternatively, you may call (972) 454-9309 to schedule an evaluation immediately. Mandatory fields are marked with a (*)

Payment Policy

Co-pays and Co-insurances are due at the time of service, or full payment is due for self-pay patients unless prior arrangements have been made with our billing department. We accept cash or credit cards (Visa, MasterCard and Discover). On a limited basis checks may be accepted and there is a service charge on any returned check; payment in full will be required within 10 days of notice.


Our office will kindly bill your insurance company. We participate with a number of medical insurance plans that we will contact to verify eligibility and benefits. Please realize that you have the ultimate responsibility of verifying the coverage with your insurance. You acknowledge that we may be an out of network provider with your insurance. You are also aware that in some circumstances your insurer will send payment directly to you. You agree to endorse the insurance check and forward funds to the appropriate entity above within 30 days of receipt. You will be responsible for any balance not paid or denied by your insurance carrier. Patients who do not supply accurate insurance information will be considered self-pay. You must inform our office of any changes in your insurance, as you are the policyholder and it is your responsibility.