Guardian Name *

First Name

Last Name

Phone *

(###)

###

####

Insurance *

We will run your benefits before the evaluation for pricing. United Healthcare, Cigna, and Aetna unfortunately outsource therapy billing to third parties which are very difficult to work with (for us and you!). We have chosen to remain Out Of Network with them due to these issues. However, we have found Out Of Network benefits are not too far off from In Network benefits. Our goal is to keep Out of Network and In Network rates similar. We have fair and comparable rates for Out Of Network and Private Pay. I have:

Aetna: Out of Network

Blue Cross Blue Shield

Cigna: Out of Network

Tricare

United Healthcare: Out of Network

None of the above, I will be private pay.

What is your child's name? *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Therapy Services *

I am interested in:

Speech Therapy

Feeding Therapy

Physical Therapy

Occupational Therapy

I am unsure

Please check boxes that match your concerns:

My child is not eating a variety of foods

My child's language or vocabulary is smaller when compared to similarly aged children

My child's articulation or sounds in language are different when compared to similarly aged children

My child's play and social skills are different when compared to similarly aged children

My child's emotional and coping skills are different when compared to similarly aged children

My child's writing skills are different when compared to similarly aged children

My child's physical or motor skills are different when compared to similarly aged children

My child needs rehabilitation from injury or surgery

Appointment Preferences (check all that apply)

Early Morning 8:00 am - 10:00 am

Mid Morning 10:00 am - 12:00 pm

Early Afternoon 12:00 pm - 2:00 pm

Afternoon 2:00 pm - 4:00 pm

Late Afternoon 4:00 pm - 6:00 pm

How did you hear about us? *

Friend or family

JV News page

Internet search

My doctor

Other