Refer My Child

• Child's First Name* First
• Child's Last Name* Last
• Child's Date of Birth*
• Parent/Guardian Name* First Last
• Relationship to Patient*MotherFatherRelativeLegal GuardianOther
• Phone Number*
• Email Address*
• Service/Evaluation Requested*
  • Speech/Language Therapy
  • Physical Therapy
  • Occupational Therapy
  • Feeding Therapy
  • Aquatic Therapy
  • LEGO Skill Builders Club
  • Go Baby Go (Modified Power Wheels)
  • Autism Diagnostic Testing (ADOS)
  • First Steps
• What concerns do you have for your child related to your requested therapy above?*Please feel free to include any additional information you'd like to share about your child.
• Scheduling Preferences*Please note we effort to schedule your evaluation for the same day and time that ongoing therapy would take place if you qualified for services. When noting your availability, please consider what day and time would work for a standing appointment on a weekly basis.
• How Did You Hear About Us?*
  • Friend/Family Member
  • Building Signage/Drove By
  • Physician
  • Insurance Company
  • Current/Previous Patient
  • Social Media
  • Indy Kids Magazine
  • Google Search
• CAPTCHA

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