Therapy form Please enable JavaScript in your browser to complete this form. - Step 1 of 6Basic InformationPatient Name *FirstLastBirthdateGenderMaleFemalePreferred LanguageEnglishSpanishParent/Guardian Name (if minor)Relationship to PatientParentGrand ParentSiblingGuardianOtherEmail *Phone *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeNextClinical & Therapy HistoryPrevious Diagnoses (if known):Current Challenges or Areas of Concern:Previous Provider Name and Contact Info:How many hours per week of each therapy have you received?:Reason for transferring or starting services:NextAvailabilityWhat days and times are you available for therapy?:Preferred Start Date: Preferred Therapist Gender (if any): MaleFemaleNextInsurance InformationPrimary Insurance Provider Name:Member ID / Policy Number:Upload Insurance Card (front & back): Click or drag files to this area to upload. You can upload up to 2 files. NextAbout the ServiceDo you have an active plan of care from another provider? (Yes/No):YesNoPreferred Place of Service (check all that apply):ClinicHomeSchoolPPECTeletherapyWhich services are you interested in? (check all that apply):Active evaluation from another clinicSpeech TherapyOccupational TherapyPhysical TherapyFeeding TherapySocial Skills TherapyReading/Academic TherapyFirst-time EvaluationOngoing Therapy from Another ProviderNextConsent * Clear Signature By submitting this form, I consent to the collection of this information for the purpose of evaluating and coordinating care services.Submit
