Quotation Estimate Speech Therapist in United States Los Angeles –Free Word Template Download with AI
Professional Speech Therapist Services
United States Los Angeles | California
Quote No: QTE-2025-0847Provider Information
ClearVoice Speech & Language Center
4820 Wilshire Boulevard, Suite 310
Los Angeles, California 90036
United States
Phone: (213) 555-0142
Email: [email protected]
CA License No. SLP-2019-44782
Client Information
Prepared For:
Mr. David R. Thompson
1247 Sunset Boulevard, Apt 5B
Los Angeles, California 90026
United States
Phone: (310) 555-8891
Email: [email protected]
Quotation Details
Date of Issue: June 15, 2025
Valid Until: July 15, 2025
Service Location: United States Los Angeles
Payment Terms: Net 30 Days
Referral & Insurance
Referring Physician: Dr. Angela Martinez, MD
Insurance Provider: Blue Cross Blue Shield of California
Policy Number: BCBS-CA-7729104
Pre-Authorization: PA-2025-3381
This Quotation Estimate outlines the comprehensive Speech Therapist services to be provided to the client in the United States Los Angeles metropolitan area. The Speech Therapist assigned to this case, Ms. Karen Whitfield, M.S., CCC-SLP, is a licensed and certified professional with over twelve years of experience in pediatric and adult speech-language pathology. The treatment plan has been developed following an initial comprehensive assessment conducted on June 2, 2025, at our Los Angeles clinic facility.
| Item # | Service Description | Frequency | Duration | Unit Rate | Estimated Total |
|---|---|---|---|---|---|
| 1 | Initial Comprehensive Speech-Language Assessment (articulation, fluency, voice, language comprehension and expression) | One-time | 90 minutes | $275.00 | $275.00 |
| 2 | Individual Speech Therapist Therapy Sessions – Articulation and Phonological Disorders (targeting /r/, /l/, and /s/ sound production) | 2x per week | 45 min/session | $145.00 | $4,640.00 |
| 3 | Fluency Therapy – Stuttering Intervention Program (Lidcombe Method adapted for adult client) | 1x per week | 50 min/session | $160.00 | $2,560.00 |
| 4 | Home Practice Program Development and Parent/Caregiver Training (United States Los Angeles area coordination) | 2 sessions | 60 min/session | $120.00 | $240.00 |
| 5 | Progress Monitoring and Reassessment (mid-program and end-of-program evaluations) | 2 assessments | 60 min/each | $195.00 | $390.00 |
| 6 | Written Progress Reports and Insurance Documentation (monthly billing support for United States Los Angeles healthcare providers) | Monthly | — | $45.00 | $270.00 |
| 7 | Telehealth Follow-Up Consultation (remote session for client convenience within the United States Los Angeles region) | 1x per month | 30 min/session | $85.00 | $255.00 |
| TOTAL ESTIMATED COST (12-Week Program) | $8,630.00 | ||||
The Speech Therapist treatment program outlined in this Quotation Estimate is designed for a twelve-week period commencing June 23, 2025, and concluding September 12, 2025. All in-person sessions will be conducted at our primary clinic located in the heart of the United States Los Angeles community, specifically in the Westside neighborhood. The Speech Therapist will maintain a consistent schedule to ensure continuity of care, with sessions scheduled between 9:00 AM and 5:00 PM, Monday through Friday. Should the client require rescheduling due to unforeseen circumstances, a minimum of 24 hours' notice is required to avoid a no-show fee of $75.00 per missed appointment.
1. Validity: This Quotation Estimate is valid for thirty (30) days from the date of issue. After the expiration date, pricing may be subject to revision based on current market rates for Speech Therapist services in the United States Los Angeles area.
2. Payment: A 20% deposit ($1,726.00) is due upon acceptance of this Quotation Estimate to secure the client's appointment schedule with the assigned Speech Therapist. The remaining balance will be invoiced monthly in accordance with the Net 30 payment terms. All payments are accepted via check, credit card, ACH transfer, or HSA/FSA reimbursement.
3. Insurance Coordination: Our office in United States Los Angeles will submit all applicable claims to the client's insurance provider. The client is responsible for any co-pays, deductibles, or non-covered services as determined by their specific policy. This Quotation Estimate reflects standard cash-pay rates; insurance reimbursement amounts may vary.
4. Cancellation Policy: The client may cancel the program at any time with written notice. In the event of early termination, a prorated refund will be issued for sessions not yet conducted, less any administrative fees of $150.00.
5. Confidentiality: All client records, assessment data, and therapy progress notes are maintained in strict accordance with HIPAA regulations and California state privacy laws. The Speech Therapist and all staff members are bound by professional confidentiality agreements.
6. Scope Limitation: This Quotation Estimate covers the specific speech-language pathology services enumerated above. It does not include audiological evaluations, occupational therapy, psychological counseling, or medical interventions. Additional services may be recommended by the Speech Therapist during the course of treatment and will be subject to a separate Quotation Estimate.
7. Governing Law: This agreement shall be governed by the laws of the State of California, United States. Any disputes arising from this Quotation Estimate shall be resolved through mediation in Los Angeles County, California.
By signing below, the client acknowledges receipt and acceptance of this Quotation Estimate for Speech Therapist services in the United States Los Angeles area. The client agrees to all terms and conditions stated herein and authorizes ClearVoice Speech & Language Center to commence the outlined treatment program.
Client SignatureDavid R. Thompson
Date: _______________ Authorized Representative
Karen Whitfield, M.S., CCC-SLP
ClearVoice Speech & Language Center
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
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