Referrals

How to Make a Referral/Appointment

Provider

A provider may refer a client for services by calling or faxing the client's information.

• Call (434)395-2972
• Fax (434)395-2622

What we need:

• Services needed/requested
  • Speech-language evaluation
  • Hearing evaluation
  • ADOS testing
• Client’s demographic information
  • Name of the responsible party (if different from the client)
  • Name of referring physician/provider
• Primary insurance information
  • Name
  • Number
• Secondary insurance information
  • Name
  • Number

Self

You may call, fax, or walk into our clinic and provide this information. 

Most of our services require a written order/referral from the client's primary care provider.

• Call (434)395-2972
• Fax (434)395-2622

We will need:

Basic Client Information

• Name
• Date of Birth
• Gender
• Physical Address (Street Number and Name, City/County, State, zip code)
• Mailing Address (if different from physical address)
• Phone Number
• Emergency contact information (Name, relationship to you i.e. spouse, mother, father, friend.
• Primary/Family doctor
• Referring doctor name 
• Primary and secondary insurance provider (s)

Client Health Information

• Allergies (food, medicine, latex)
• Major medical history i.e. surgeries, therapies

Forms

For registration forms, please call (434)-395-2972 or e-mail shls@longwood.edu.