Referrals

Patient Referral From
Physician Referral Form

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(Required)

Child's Last Name(Required)

Date of Birth(Required)

Services Requested(Required)

Speech Therapy

Occupational Therapy

Both

Other

Concerns/Reason for Referral(Required)

Parent's First Name(Required)

Parent's Last Name(Required)

Primary Phone(Required)

Alternate Phone(Required)

Email Address(Required)

Referred by(Required)

Parent

Teacher

Other

Referral's First Name(Required)

Referral's Last Name(Required)

Please provide any additional information(Required)

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(Required)

Physicians's Last Name(Required)

Email Address(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Patient's First Name(Required)

Patient's Last Name(Required)

Patient Date of Birth(Required)

Insurance Carrier(Required)

Patient Phone(Required)

Services Requested(Required)

Occupational Therapy

Speech Therapy

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

Primary diagnosis(Required)

Physician’s NPI#(Required)

Location(Required)

Primary Insurance Carrier(Required)

Primary Insurance Carrier Date of Birth(Required)

Our team of experts are ready to hear from you

Schedule An Appointment

Referrals

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

Our team of experts are ready to hear from you

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