Referral form

Important note:
We are private, fee-for-service clinics. This means that fees are charged to you for all services provided and you have the option to receive reimbursement through your employee benefits insurer. For information on fees, please see the "Fees" section of this site.
Prompt and personalized service is our goal.
Please fill out this referral form and you will be contacted within one business day to set up an appointment. If you are experiencing any challenges with the form please email us directly at

Fill out the form below and we will contact you during our working hours




    Elgin Speech & Language Services abides by the Personal Health Information Protection Act.
    Once it is submitted, your personal information is stored and not shared with any party – for any reason –
    without written consent to do so, unless subpoenaed by court order. For referrals received from physicians’
    offices, the referral will be confirmed with the referring party and consent will subsequently be obtained from
    the family referred for service prior to the commencement of any assessment, treatment, or consultation service.

    I have read and understood the above statement and agree to proceed with this referral