Patient Forms

Most forms are fillable pdfs and can be filled in on the computer and either printed and brought in the day of your appointment or emailed to  Please submit the Patient Services Agreement and applicable Intake Form.

If your child receives school-based special education services please bring a copy of the most current Multidisciplinary Education Team (MET) paperwork, Individualized Education Plan (IEP) and any medical reports.

12 months – 5 years
6 years – 17 years
NSLC Patient Services Agreement

NSLC Intake for Preschool Age


NSLC Patient Services Agreement

NSLC Intake for 6-17 years



OMD Pediatric Intake

OMD Adult Intake

NSLC Patient Services Agreement

OMD Observation Sheet

Evaluation Appointments

FOR ALL EVALS (Speech, Language, Orofacial Myofunctional): Bring the completed paperwork, 1/2 a sandwich of your choice, a pureed snack with spoon (i.e. pudding, yogurt, applesauce) AND a finger snack (i.e. pretzels, chips, goldfish etc).  FOR OMD: If possible, please also bring pictures of the patient sleeping, watching TV, working on the computer or holding a handheld device.  A 2-3 minute video the patient sleeping is also helpful. FOR SPEECH/LANGUAGE: If you have a current IEP and/or MET submit via email or drop off prior to the appointment.

Online Resources

Speech and Language: American Speech-Language-Hearing Association

Orofacial Myofunctional Therapy: International Association of Orofacial Myology


Insurance Tips

All services provided at NSLC are private pay and fees will be collected on the day of service.  Following payment, NSLC will provide the paperwork that will contain the insurance codes that are required by insurance providers.  It is the patient’s responsibility to submit the appropriate paperwork to their insurance providers for possible reimbursement.  When communicating with your insurance company, it is important that you are prepared to ask and answer questions.  Below are a few suggestions, provided to us by our patients, to help make your experience with your insurance provider a meaningful one.  It is important that you take detailed notes including the date, name, number, and extension of the person with whom you spoke to.   Questions to Ask your Insurance Provider: Does my policy cover speech and language therapy for an out-of-network, private practice provider? If speech and language are a covered benefit:  Do I have a deductible, how many sessions are covered, what percentage of the fee will I be reimbursed? What form(s) do I have to submit prior to receiving my insurance benefits?