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Tel: 919- 378-1340
Fax/Referral: (888) 975-6815
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About Us
Our Promise
Our Mission
Our Team
Speech Therapy
Occupational Therapy
Physical Therapy
ABA
Mental Health & Psych Evaluations
Admin
Take a Virtual Tour!
Clinical Policies
Our Services
Occupational Therapy
Physical Therapy
Speech + Language Therapy
Feeding Therapy
Applied behavioral analysis (ABA)
Teletherapy
Dyslexia
Mental Health
Patient Resources
FAQ
Pediatrician & Clinic Partnerships
Milestones
Need A Ride?
Payments and Insurance
Pay Online
Funding Resources
Coupon
Pediatrician & Clinic Partnerships
Success Stories
Gallery of Triumphs!
School Services
Media
Articles and Podcast Interviews
Awards and Recognitions
Blog
Parent Portal
Therapy Smarts: Refer a Patient
Thank you for referring the patient to us.
Date of Referral:
Patient Name:
Date of Birth:
Physician Name:
Physician Phone #
Fax #
Contact Information
Parent/Guardian Name:
Phone # H:
Cell:
Address:
Email:
Insurance Company:
Medicaid:
Yes
No
*Insurance/Medicaid ID # (Please include alpha characters):
Case Manager (if any) Information:
Day Care (if any) Information:
Referring Professional:
Name:
First
Middle Initial
Practice:
Address:
City / State / Zip Code:
Phone Number:
Fax Number:
Diagnosis:
Reason For Referal:
SLP
OT
Feeding
PT
Psychological Evaluation
Mental Health
ABA (Applied Behavior Analysis)
Evaluate
Treat
Send