Referral Form

Pediatric Referral Form — Secure and Encrypted

Who can fill out this form? Doctors, agencies, caregivers, family members, or the person seeking improvement in his or her life.

Please only submit the name of a minor if you have permission of the legal parent or guardian.

We select the appropriate therapist, or therapy team, based on concerns identified.

We will contact you (or the parent, guardian, or caregiver) discuss your best options within 1 to 2 business days.