Referral Programs:

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  • Complete our Referral Form below or contact our clinic.
  • Our staff will obtain a physician’s signed request for an evaluation for treatment.
  • Insurance benefits will be verified.
  •  Client’s caregiver/parent will be reached by phone to schedule the initial visit.
  • After the initial visit for an evaluation, the evaluating therapist will recommend the frequency of services and assist the family with scheduling appointments

Please let us know how we can help you!  Fill out the form below and we will contact you shortly.

    Child's First Name

    Date of Birth

    Services Requested

    Concerns/Reason for Referral

    Parents's First Name
    Primary Phone

    Referred by

    Referral's First Name

    Please provide any additional information:

    For referrals, please contact our office at 480-508- 7566.

    • Please provide signed orders for an evaluation and ongoing treatment.
    • Our staff will verify insurance benefits.
    • Client’s caregiver/parent will be reached by phone to schedule a phone or in-person intake.
    • After intake and insurance verification, the office scheduler will call to schedule an inital evaluation.
    • Based on the results of that evaluation, ongoing therapy sessions and frequency of services will be recommended.
    • The therapist and office staff will assist the family with scheduling appointments.

    Download, print, and fill out the Physician’s Referral Form.
    You can also complete our online form below.

      Physicians's First Name

      Email Address

      Address

      Address 2

      City
      Zip
      Patient's First Name

      Patient Date of Birth

      Insurance Carrier

      Patient Phone

      Services Requested

      All information below MUST be provided by the physician so that an evaluation can be scheduled.

      Primary diagnosis *

      Physician’s NPI# *

      Location

      Primary Insurance Carrier*

      Primary Insurance Carrier Date of Birth*

      You may also fax your own referral form to our office at 928-212- 9014. Please note: If you choose Prescott Valley location, we do not offer OT services at that this time.

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