Name and Phone of PARENT:
Complete ADDRESS of Appointment (If the interpreter is needed through Telehealth, you don't need to provide the address):
IF YOU HAVE A LINK TO A <> SESSION, YOU CAN INCLUDE IT HERE (Also, if no interpreter is available to go in person, you will be notified, and you will be provided with an interpreter through Telehealth):
Who will be the PROVIDER?
Type of Service (PT, OT, ST, BCBA, DI, VISUAL, AUDIO, ETC.)
Provider's CELL PHONE (Please do NOT provide landlines)
Date for the Initial Appointment:
Is this a ONE TIME or an ONGOING appt.? If ONGOING, please SPECIFY FREQUENCY.
How long should we book our interpreter for THIS session?
Who should we bill? (Please specify CCB as we do not bill Medicaid)