How to Make a Referral/Appointment



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

  • Calling 434-395-2972
  • Faxing 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 our office at 434-395-2972 or walk into our clinic and provide this information. Any of this information may be faxed to 434-395-2622.

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

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


You may print and bring your completed registration form packet on the day of your appointment if you choose.

There are 3 different types of form packets:

  • Audiology Adult
  • Audiology Child
  • Speech-language

Please call our office if you are unsure of which form packet to complete for your appointment.