Contact Us
Patient & Family Referral
Complete this HIPAA-compliant form: CLICK HERE​
Or, if you're contacting us via fax or phone to begin services, please have the following information ready:​
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State where services are needed
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Full name of client
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Phone number
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Email
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​Date of birth of client
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Your full name (if different the client)
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Relationship to client (if not client)
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Availability for ongoing services
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Home address
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Types of services needed (Occupational Therapy, Physical Therapy, Speech Language Therapy
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Primary insurance name, policy #, ID number
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Primary insurance policy holder name
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Secondary insurance name, policy #, ID number (if applicable
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Secondary insurance policy holder name
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Name of client's doctor (Note: Medicaid requires a recent visit, within the past 90 days, to the PCP)
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Doctor's office/clinic name
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Date of last visit to doctor (if known)
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How did you hear about us?
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Physician Referral
Fax your referral form and required medical records (including ICD-10, allergies and medications, order for evaluation, and visit note) to (719) 425-3656
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