REFERRAL FROM PARENTS/OTHER 

  • Complete our Referral Form below or contact our clinic (link to phone number/contact info)
  • 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 Name *
Child’s Name
Service Requested
Parent Name *
Parent Name
Phone Number *
Phone Number
Alternate Phone Number
Alternate Phone Number
Referred by
Name
Name