Referral Forms
All of the forms on this page are downloadable in pdf format. (If you do NOT have the free Adobe Acrobat Reader, you will need to download it onto your computer before you will be able to open the forms on this page.) Alternative formats of these forms are available, upon request.
Family Physicians are most welcome to refer their adolescent and adult patients to Talk in Action for speech, voice, language, or swallowing assessment and treatment. Please click on the link above, print the referral form, complete it, and fax it to the attention of Talk in Action. Alternatively, you may scan the completed form and return it by e-mail to rjwelland@talkinaction.net. Thank you.
Laryngologists/otolaryngologists are most welcome to refer their adolescent and adult voice and head and neck cancer patients to Talk in Action for speech, voice, or swallowing assessment and treatment. Please click on the link above print the referral form, complete it as completely as possible, and fax it to the attention of Talk in Action. Alternatively, you may scan the completed form and return it by e-mail to rjwelland@talkinaction.net. Thank you.
Neurologists and neurosurgeons are most welcome to refer their adolescent and adult patients with neurological conditions, diseases, or disorders (e.g., stroke, traumatic brain injury, concussion, brain tumour, ALS, MS, Parkinson disease) to Talk in Action for speech, voice, language, or swallowing assessment and treatment. Please click on the link above, print the referral form, complete it, and fax it to the attention of Talk in Action. Alternatively, you may scan the completed form and return it by e-mail to rjwelland@talkinaction.net. Thank you.
Other Specialist Physicians/Other Health Care Practitioners
Other specialist physicians and other health care practitioners are welcome to refer their adolescent and adult patients with speech, language, or swallowing disorders to Talk in Action for assessment and treatment. Please click on the link above, print the referral form, complete it, and fax it to the attention of Talk in Action. Alternatively, you may scan the completed form and return it by e-mail to rjwelland@talkinaction.net. Thank you.