Referral Programs:

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  • Complete our Referral Form below or contact our clinic.
  • 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 First Name

Date of Birth

Services Requested

Concerns/Reason for Referral

Parents's First Name
Primary Phone

Referred by

Referral's First Name

Please provide any additional information:

For referrals, please contact our office at 480-508- 7566.

  • Please provide signed orders for an evaluation and ongoing treatment.
  • Our staff will verify insurance benefits.
  • Client’s caregiver/parent will be reached by phone to schedule a phone or in-person intake.
  • After intake and insurance verification, the office scheduler will call to schedule an inital evaluation.
  • Based on the results of that evaluation, ongoing therapy sessions and frequency of services will be recommended.
  • The therapist and office staff will assist the family with scheduling appointments.

Download, print, and fill out the Physician’s Referral Form.
You can also complete our online form below.

Physicians's First Name

Email Address

Address

Address 2

City
Zip
Patient's First Name

Patient Date of Birth

Insurance Carrier

Patient Phone

Services Requested

All information below MUST be provided by the physician so that an evaluation can be scheduled.

Primary diagnosis *

Physician’s NPI# *

Location

Primary Insurance Carrier*

Primary Insurance Carrier Date of Birth*

You may also fax your own referral form to our office at 928-212- 9014. Please note: If you choose Prescott Valley location, we do not offer OT services at that this time.

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