Child's First Name*

Child's Last Name*

Child's Birthday*

What is your goal for seeking a therapy evaluation?*

Finish this sentence. "If only someone could help me_________."*

Child's Sex Assigned At Birth*

Male

Female

Child's Gender Pronouns*

She

They

Please indicate if your child has any diagnosis or additional medical need(s). Check all that apply.*

Check all applicable.

Please Specify (Other current diagnosis or medical needs)

Please check all of your current concerns.*

Check all applicable.

Child's Pediatrician First Name*

Child's Pediatrician Last Name*

Pediatrician's Practice Name*

Practice Phone Number

e.g. (555) 555-5555

To meet your child’s therapy needs as soon as possible, please provide all days & times you are available for ongoing therapy sessions. Note: There is currently a waitlist for after–school appointments (3 PM – 7 PM), with preference being given to our current clients. If you’re looking for after-school appointments only, we strongly encourage you to consider getting started with treatment times outside of the after-school timeframe.

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Monday

e.g. 9am-11:30am

Monday

8am - 12pm

12pm - 3pm

3pm - 6pm

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Tuesday

e.g. 9am-11:30am

Tuesday

8am - 12pm

12pm - 3pm

3pm - 6pm

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Wednesday

e.g. 9am-11:30am

Wednesday

8am - 12pm

12pm - 3pm

3pm - 6pm

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Thursday

e.g. 9am-11:30am

Thursday

8am - 12pm

12pm - 3pm

3pm - 6pm

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Friday

e.g. 9am-11:30am

Friday

8am - 12pm

12pm - 3pm

3pm - 6pm

If your availability is limited to 3 PM or later only, the wait time for a consistent weekly spot with the same therapist is currently about 12 months or longer. While we work toward finding that regular time, we encourage families to consider joining our cancellation list. This gives your child the chance to be seen sooner when openings come up, even if it’s not always with the same therapist. Starting therapy earlier can make a real difference; your child can begin learning new skills, gaining confidence, and practicing strategies at home, all of which helps set the stage for smoother progress once a consistent spot is available.

Please click YES below if you're open to flexible scheduling, and NO below if you believe a consistent, ongoing time each week with the same therapist is the best for your child.

Open to Flexible Scheduling*

Yes

Parent/Guardian's First Name*

Parent/Guardian's Last Name*

Parent/Guardian's Phone Number*

e.g. (555) 555-5555

Parent/Guardian Email Address*

e.g. name@example.com

Parent/Guardian's Address*

Street Address Address Line 2 City State ZIP Code

Please indicate the preferred clinic location where you are seeking services*

In order to start services for your child sooner, are you open to being scheduled at a different location?*

Yes

What services are you seeking?*

Check all that apply

Occupational Therapy

Speech Therapy

Physical Therapy

I'm unsure

Will you be using insurance?*

Yes

No, I will be paying privately

Select Your Primary Insurance Carrier*

Please Specify (Other Primary Insurance)*

Select Your Secondary Insurance Carrier*

Please Specify (Other Secondary Insurance)*

First and Last Name of Insured*

Insured's Date of Birth*

Primary Insurance ID*

Secondary Insurance ID*

Upload Insurance Card - Front Side*

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Max. file size: 50 MB.

Insurance companies require that we have both the Primary and Secondary insurance cards on file to ensure proper Coordination of Benefits (COB). If you have Primary and Secondary coverage, please send copies of both insurance cards.

Upload Insurance Card - Back Side*

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Max. file size: 50 MB.

How did you hear about us?*

Current or Previous Playabilities Family*

Seeking Services for Same Child

Seeking Services for Sibling

Where on the Web did you find us?*

Facebook

Instagram

Google

Video

Name of Physician/Pediatrician*

Name of School*

Name of Playabilities Employee*

Name of Referral*

Name of Medical Practice*

Name of Parent Educator*

Name of School*

Please Specify (Other, How did you hear about us?)*

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Parent Email Notification - OON

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Parent Email Notification - In Network

This field is for validation purposes and should be left unchanged.

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