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Tel: 919- 378-1340
Fax/Referral: (888) 975-6815

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About Us
Our Services
Patient Resources
Success Stories
- Gallery of Triumphs!
School Services
Media

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:

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*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:

SLPOTFeedingPT Psychological EvaluationMental HealthABA (Applied Behavior Analysis)

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Therapy Smarts, Inc is a pediatric clinic offering Speech therapy, Physical therapy, Occupational therapy, Psychological evaluations, Mental Health therapy, and ABA services to children of all ages and diagnoses.

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Durham clinic -
1920 NC-54 STE 240, 360, Durham, NC 27713
Chapel Hill clinic -
1130 Weaver Dairy Rd, Chapel Hill, NC 27514
Call: 919-378-1340

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