Quotation Estimate Speech Therapist in United States Chicago –Free Word Template Download with AI
Professional Speech Therapist Services — United States Chicago
Service Provider
Chicago Speech & Language Therapy Center
1420 N. Lake Shore Drive, Suite 310
Chicago, Illinois 60610
United States
Phone: (312) 555-0187
Email: [email protected]
License No.: IL-SP-2024-08841
Prepared For
Client Name: [Client / Organization Name]
Address: [Street Address]
Chicago, Illinois [ZIP Code]
United States
Contact: [Phone / Email]
Referral Source: [Physician / Insurance / Self]
This Quotation Estimate is issued by Chicago Speech & Language Therapy Center to provide a comprehensive, itemized financial projection for the professional services of a licensed Speech Therapist operating within the United States Chicago metropolitan area. This document outlines the anticipated costs, service deliverables, scheduling parameters, and applicable terms governing the engagement. The Speech Therapist services described herein are tailored to the specific communicative, articulatory, and language-processing needs of the client as identified during the initial clinical assessment conducted on May 28, 2025.
| Item | Description | Frequency | Unit Rate | Subtotal |
|---|---|---|---|---|
| 1 | Initial Comprehensive Speech & Language Assessment (administered by a certified Speech Therapist in Chicago, IL) | One-time | $275.00 | $275.00 |
| 2 | Individual Speech Therapy Sessions (articulation, phonology, and fluency intervention) | 2x / week × 12 wks | $150.00 | $3,600.00 |
| 3 | Group Speech Therapy Session (small cohort, max 4 participants, United States Chicago clinic) | 1x / week × 12 wks | $95.00 | $1,140.00 |
| 4 | Home Practice Program Design & Parent/Caregiver Training (delivered by the assigned Speech Therapist) | 2 sessions | $125.00 | $250.00 |
| 5 | Mid-Progress Re-Evaluation (week 6) — conducted by the Speech Therapist in Chicago | One-time | $175.00 | $175.00 |
| 6 | Final Outcome Assessment & Discharge Report (certified by the Speech Therapist, United States Chicago) | One-time | $200.00 | $200.00 |
| 7 | Therapeutic Materials, Augmentative Communication Tools & Digital Resources | One-time | $85.00 | $85.00 |
| 8 | Administrative & Scheduling Coordination (United States Chicago office overhead) | 12 weeks | $25.00 | $300.00 |
| Subtotal | $6,025.00 |
| Illinois State Sales Tax (10.25%) | $617.56 |
| Insurance Coordination Fee (if applicable) | $0.00 |
| GRAND TOTAL (USD) | $6,642.56 |
3.1 Validity: This Quotation Estimate remains valid for thirty (30) calendar days from the date of issue. Should the client wish to proceed beyond the expiration date, a revised Quotation Estimate reflecting current Speech Therapist availability and prevailing United States Chicago market rates will be issued.
3.2 Payment Schedule: A deposit of twenty-five percent (25%) of the Grand Total is due upon acceptance of this Quotation Estimate. The remaining balance shall be invoiced bi-weekly in accordance with the session schedule. All payments are due within fourteen (14) days of invoice receipt. Late payments are subject to a 1.5% monthly interest charge as permitted under Illinois state law.
3.3 Cancellation Policy: Sessions must be rescheduled or cancelled with a minimum of twenty-four (24) hours' notice. Cancellations made within twenty-four hours or no-shows will be billed at fifty percent (50%) of the applicable session rate. This policy applies to all Speech Therapist appointments conducted at our United States Chicago facility.
3.4 Insurance and Billing: This Quotation Estimate reflects self-pay rates. If the client elects to submit claims through a health insurance provider, the Speech Therapist and our billing office in Chicago will coordinate directly with the insurer. Pre-authorization documentation will be provided upon request. The client remains responsible for any co-pays, deductibles, or non-covered services.
3.5 Confidentiality: All clinical records, assessment data, and therapeutic progress notes are maintained in strict compliance with the Health Insurance Portability and Accountability Act (HIPAA) and applicable Illinois state privacy statutes. No information will be disclosed without written client consent.
3.6 Scope Limitation: The Speech Therapist services outlined in this Quotation Estimate are limited to the interventions specified in Section 2. Any additional diagnostic testing, extended therapy beyond twelve weeks, or specialized services (e.g., pediatric feeding therapy, voice pathology) will require a separate written amendment to this Quotation Estimate.
3.7 Governing Law: This Quotation Estimate and any resulting service agreement shall be governed by and construed in accordance with the laws of the State of Illinois, United States. Any disputes shall be resolved through mediation in the City of Chicago, Cook County, Illinois.
Note: This Quotation Estimate is a good-faith financial projection and does not constitute a binding contract until signed and countersigned by both parties. The assigned Speech Therapist in our United States Chicago practice holds a Master's degree in Speech-Language Pathology, is certified by the American Speech-Language-Hearing Association (ASHA), and maintains an active Illinois state license. All rates are quoted in United States Dollars (USD).Client / Authorized Representative:
Name: ______________________________
Date: ______________________________
Chicago Speech & Language Therapy Center
(Authorized Speech Therapist / Practice Manager)
Name: ______________________________
Date: ______________________________
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