Child's First Name*

Child's Last Name*

Child's Birthday*

Primary reason you are seeking treatment?

Child's Sex Assigned At Birth*

Male

Female

Child's Gender Pronouns*

She

They

Does your child have a current diagnosis?*

Check all applicable.

Please Specify (Other current diagnosis)*

Is your child currently receiving services, or have they in the past?

If yes, please explain

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 evaluation and 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.

Monday

e.g. 9am-11:30am

Tuesday

e.g. 9am-11:30am

Wednesday

e.g. 9am-11:30am

Thursday

e.g. 9am-11:30am

Friday

e.g. 9am-11:30am

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?)*

Phone

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

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