Occuplaytional Therapy Associates

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Child DOB

Administrative

Referral source

Enter how you were referred to our services

Billing & Payment

Payment method

How do you plan to pay?

Insurance Company Name

Insurance card upload

Upload a photo of your insurance card

Primary Insured Name

Limited to 600 characters

Primary Insured Date of Birth

Child Name

Insurance Plan ID Number

Client Preferences

Preferred appointment times

Morning Afternoon Evening Weekend

Reason for care

Please provide a brief description of why you are seeking occupational therapy services for your child.

e.g. Fine Motor Skills, Sensory Processing, Visual Motor Skills, Handwriting, Attention

Limited to 600 characters

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.