Complete ADDRESS of appointment:
If this is a TELEHEALTH appointment, please include the LINK here:
Type of Service (PT, OT, ST, BCBA, DI, VISUAL, AUDIO, INTAKE, TRANSITION, INITIAL, ETC.):
Provider's CELL PHONE (Please do NOT provide landlines):
DATE and TIME of the 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)