Has the patient been here before? *

Yes

No

What is the patient's name? *

First Name

Last Name

What is the patient's DOB? *

MM

DD

YYYY

What is the patient's gender? *

Male

Female

What is the patient's address? *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

The patient is: *

a child

an independent adult

an adult requiring the help of a caregiver to receive services

What is the patient's primary physician's name? *

First Name

Last Name

Does the patient have primary insurance? *

Yes

No (Self-pay)

Is there a secondary insurance? *

Yes

No

What is your preferred location? *

Missouri City Clinic

Katy Clinic

I am interested in receiving the following therapy services: *

Check all that apply:

Speech Therapy

Feeding Therapy

Occupational Therapy

Myofunctional Therapy

Has the patient received any medical or educational diagnoses? *

Check all that apply. To begin your journey, documentation of diagnosis will be requested.

No

Autism Spectrum Disorder

Down Syndrome

ADHD

Intellectual Disability

Other

Has the patient received evaluations previously? *

Check all that apply. If the patient has had any therapy evaluations within the past year, we may be able to begin therapy without a new evaluation. To begin your journey, copies of any previous reports will be requested.

Speech therapy evaluation

Occupational therapy evaluation

Feeding/Myofunctional therapy evaluation

Developmental/Neurological/Educational evaluation

None

Is a language other than English used at home? *

Yes

No