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
- Secondary insurance information
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.