Refer My Child

Child's Name*
First Last
Child's Date of Birth*
MM slash DD slash YYYY
Parent/Guardian Name
First Last
Relationship to Patient
Phone Number*
Email Address*
Street Address
Street Address Address Line 2 City State ZIP Code
Service/Evaluation Requested*
- First Steps
- Speech/Language Therapy
- Physical Therapy
- Occupational Therapy
- Feeding Therapy (Group/Individual)
- Autism Diagnostic Testing (ADOS)
- Preschool Prep Summer Camp
- LEGO Skill Builders Club
- Therapeutic Yoga
- Speech Playgroup
- Social Skills Playgroup
- Gross Motor Playgroup
- It Takes Two to Talk Hanen Program
- Social Work
Already Have A Therapy Prescription?*
- Yes
- No
Primary Insurance*
- Anthem
- Blue Cross/Blue Shield
- Cigna
- Aetna
- UnitedHealthcare/UMR
- Tricare
- Traditional Medicaid
- Anthem Medicaid
- UHC Medicaid
- MDWise Medicaid
- MHS Medicaid
- Self Pay
- Other
Insured's Name*
First Last
Member ID Number*

Can be found on the Front of your insurance card.
Insurance Provider Services Phone Number
Can be found on the Back of your insurance card.
Primary Care Physician's Name
First Last
Primary Care Physician Phone Number
Primary Care Physician Practice Location
Scheduling Preferences
Please include at least two days and/or times you would be available for an evaluation. Also, please indicate your ongoing availability for a regular weekly appointment.
How Did You Hear About Us?*
- Physician
- Friend/Family Member
- Building Signage/Drove By
- Facebook
- Instagram
- Twitter
- Google Search
- Other
Notes
Please feel free to include any additional information you'd like to share about your child.
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