Please submit completed forms prior to your evaluation appointment. Please also have your child's PCP fax a script for your desired therapy(s) to 717-370-6315. Please contact us with any questions!
Client Information:
Insurance and Billing Information:
Write "same" if same as primary address above
Please bring your card with you to your appointment.
Please bring your card with you to your appointment
Family Information:
Preschool/School Information
Which therapies and how often, ex. ST 30 mins per week
Medical Information
Write N/A if your child does not have a diagnosis
No need to list specific providers here, just disciplines. For example, "neurologist, developmental pediatrician"
Client Profile
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Next Steps
Please submit completed forms prior to your evaluation appointment. Please also have your child's PCP fax a script for your desired therapy(s) to 717-370-6315. Please contact us with any questions!