Appointment Scheduling Request Form

Appointment Scheduling Request Form

Pediatric Development Center of Atlanta, LLC

3200 Highlands Pkwy SE Ste 150

Smyrna, GA 30082

770-433-2300

Parent/Legal Guardian Name*

First NameLast Name

Child's Legal Name*

First NameLast Name

Child's Date of Birth*

Relationship to Child*

Therapy Services Requested*

Occupational TherapySpeech TherapyFeeding Therapy

Please be advised 8:00 am, and mid afternoon times (2:00 pm - 5:00 pm) typically have longer wait lists as these are the most frequent requested times. Ocupational Therapy normaly begins on the hour for 53 minute sessions. Speech and Feeding Therapy can begin on the hour or half hour for 25 minute sessions.

First Priority Time and Day of the Week*

Second Priority Time and Day of the Week*

Third Priority Time and Day of the Week*

Is Your Schedule Flexible?*

Is There a Sibling Currently Receiving Therapy You Would Like to be Paired With*

If Receiving More Than One Therapy, Would you Prefer These Services as Close Together as Possible?*

We will do our best to accommodate your therapy scheduling requests, however, please understand when Therapists have full Caseloads, or the dates and times requested are currently not available, we will place you on our Wait List. We schedule Therapy in the order of when the request was submitted, following the completion of an Evaluation by Pediatric Development Center of Atlanta, or receipt of an Evaluation completed at another Clinic if, dated within one calendar year.

Signature of Parent/Legal Guardian*

Clear

Date*

Date