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Physician/provider order form for Speech-Language Pathology (SLP) services

Thank you for entrusting Boston Children’s Hospital to partner with you on your patient’s care. The Center for Communication Enhancement offers the following programs with Speech Language Pathology Services:

• Augmentative Communication Program
• Autism Language Program
• Jay S. Fishman ALS Augmentative Communication Program
• Deaf and Hard of Hearing Program
• Feeding and Swallowing Program
• Speech-Language Pathology Program
• Voice and Velopharyngeal Dysfunction Program

If you are a physician, physician assistant, or nurse practitioner with a patient who requires non-urgent Speech Language Pathology services in one of the Center for Communication Enhancement programs listed above, please complete, print, and fax the form below to 617-730-6213. The Center for Communication Enhancement will contact the family within five business days to schedule an appointment or begin a scheduling intake process, when applicable, and close the loop with your practice.

This form is required to be completed for each new patient referral and for re-evaluation referral requests after 60 days from the original request. This form does not replace and is not an insurance referral request form, which is a separate document. If you have any further questions regarding this new process, please call 781-216-2200.

Students interestesd in observation should fill out the form at this link: www.childrenshospital.org/cce-observation.

We cannot guarantee requests for observation will be fulfilled.