Quotation Estimate Speech Therapist in United States New York City –Free Word Template Download with AI
Professional Speech Therapist Services
Brooklyn Speech & Language Therapy Center
245 West 42nd Street, Suite 1200, New York, NY 10036, United States
Phone: (212) 555-0187 | Email: [email protected]
NYS Licensed Speech-Language Pathologist | License No. NY-SLP-2019-4472
This Quotation Estimate outlines the comprehensive professional services to be provided by our licensed Speech Therapist team at our clinic located in the heart of United States New York City. The following estimate covers a structured, evidence-based intervention program designed to address the client's diagnosed speech and language disorders. All services will be delivered in accordance with the standards set forth by the New York State Education Department and the American Speech-Language-Hearing Association (ASHA). The Speech Therapist assigned to this case will conduct an initial comprehensive evaluation, develop an individualized treatment plan, and provide ongoing therapeutic sessions tailored to the client's specific needs within the United States New York City metropolitan area.
| # | Service Description | Duration | Frequency | Unit Rate | Quantity | Subtotal |
|---|---|---|---|---|---|---|
| 1 | Initial Comprehensive Speech & Language Evaluation by Licensed Speech Therapist | 90 min | One-time | $350.00 | 1 | $350.00 |
| 2 | Individualized Treatment Plan Development & Parent/Guardian Consultation | 60 min | One-time | $200.00 | 1 | $200.00 |
| 3 | Individual Speech Therapy Sessions (Articulation & Phonology Focus) | 45 min | 2x/week | $175.00 | 32 | $5,600.00 |
| 4 | Group Speech Therapy Sessions (Social Communication & Pragmatics) | 60 min | 1x/week | $125.00 | 16 | $2,000.00 |
| 5 | Progress Assessment & Treatment Plan Revision (Monthly) | 30 min | Monthly | $150.00 | 4 | $600.00 |
| 6 | Home Practice Program Materials & Digital Resources | — | One-time | $85.00 | 1 | $85.00 |
| 7 | End-of-Program Comprehensive Re-Evaluation & Discharge Report | 90 min | One-time | $300.00 | 1 | $300.00 |
| 8 | Coordination with Referring Physician & School IEP Team (United States New York City Public Schools) | 45 min | As needed | $120.00 | 3 | $360.00 |
| Subtotal | $9,495.00 |
| Applicable NYS Sales Tax (8.875%) | $842.68 |
| Insurance Adjustment (Est. 70% Coverage – Aetna PPO) | -$6,646.50 |
| Estimated Client Responsibility | $3,691.18 |
This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. Payment of the estimated client responsibility amount may be made in full upon completion of the program or in four (4) equal monthly installments of $922.80. All payments are due within fifteen (15) days of invoice date. Our office in United States New York City accepts all major credit cards, HSA/FSA cards, and electronic bank transfers. A 1.5% monthly late fee will be applied to any outstanding balance exceeding the grace period. Please note that this Quotation Estimate is based on current insurance benefit verification and is subject to adjustment should the client's coverage change during the treatment period.
Important Provisions of This Quotation Estimate
- This Quotation Estimate is a good-faith projection of costs and does not constitute a binding contract until both parties have signed and returned the acceptance form. The final invoice may vary by up to 10% based on actual sessions delivered.
- All Speech Therapist services will be performed by a New York State-licensed Speech-Language Pathologist holding a Certificate of Clinical Competence (CCC-SLP) from ASHA. The primary therapist assigned will be Dr. Margaret Chen, with Dr. Robert Okafor, M.S., CCC-SLP serving as backup.
- Sessions are scheduled at our clinic at 245 West 42nd Street, New York, NY 10036, United States New York City. Telehealth sessions via HIPAA-compliant video platform are available at the same rate for clients who require remote access.
- Cancellations must be provided at least 24 hours in advance. Late cancellations or no-shows will be billed at 50% of the session fee. Three (3) consecutive no-shows will result in a temporary suspension of services pending a rescheduling consultation.
- Client health information and treatment records are protected under HIPAA (Health Insurance Portability and Accountability Act) and New York State Public Health Law. Records will be retained for a minimum of seven (7) years in compliance with United States New York City and state regulations.
- This Quotation Estimate does not include costs for diagnostic imaging, audiological testing, or medical procedures that may be recommended by the referring physician. Such services will be quoted separately.
- The treatment program duration is estimated at sixteen (16) weeks. The Speech Therapist reserves the right to extend or modify the program based on the client's progress, with written notice and a revised Quotation Estimate provided to the client and insurance carrier prior to any extension.
- By accepting this Quotation Estimate, the client agrees to the clinic's full terms of service, privacy policy, and consent for treatment as outlined in the separate client agreement document.
Prepared By:
Dr. Margaret Chen, M.S., CCC-SLP
Director of Clinical Services
Brooklyn Speech & Language Therapy Center
Signature: ___________________________
Date: ___________________________
Client / Authorized Guardian Acceptance:
I have reviewed this Quotation Estimate and agree to the terms stated herein.
Name: ___________________________
Signature: ___________________________
Date: ___________________________
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