How to Make a Referral/Appointment



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


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


For registration forms, please call (434)-395-2972 or e-mail