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Patient Referral Form
We are excited to start a new referral for your child. Please complete the following information as soon as possible.
Child Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
Male
Female
Parent/Guardian Name:
First Name
Last Name
Phone Number
Please enter a valid phone number.
Alternate phone # (optional):
Please enter a valid phone number.
Home Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Treatment Address:
If patient is not being treated at the home address listed above, please provide us the following information: (Daycare/Group Home name and address)
Email
example@example.com
I prefer to be contacted by:
Phone
Email
Text
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Insurance
How many insurances do you have?
1
2
No insurance (Out of Pocket)
Name of Insurance company:
For example; Superior, Amerigroup, Blue-Cross Blue-Shield, United Healthcare, etc.
Name of Primary Insurance company:
For example; Superior, Amerigroup, Blue-Cross Blue-Shield, United Healthcare, etc.
ID #
Primary ID #:
Group #: if applicable
Primary Group #: if applicable
Policyholder Name: if applicable
Primary Policyholder Name: if applicable
Policyholder date of birth; if applicable
-
Month
-
Day
Year
Date
Primary Policyholder date of birth; if applicable
-
Month
-
Day
Year
Date
Name of Second Insurance: if applicable
For example; Superior, Amerigroup, Blue-Cross Blue-Shield, United Healthcare
Secondary Insurance ID #
Primary Insurance
Secondary Insurance Group #
If applicable
Secondary Insurance Policy Holder Name
If applicable
Second Insurance Policy Holder’s DOB
-
Month
-
Day
Year
Date
Primary Care Physician Name:
First Name
Last Name
Primary Care Physician’s Clinic Phone #:
Please enter a valid phone number.
Approximate date of last well child visit:
-
Month
-
Day
Year
Date
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Therapy Related
Which therapy would you like?
Speech Therapy
Physical Therapy
Occupational Therapy
What concerns/delays do you have regarding this child?
Does this child go to school?
Yes
No
what time does he/she get home?
When is your child available for therapy?
i.e: after 8 AM; anytime during the day; after they get home from school, etc.
Does the child have a foster care agency case manager/CPS case manager?
Yes
No
I don't know
Case Manager’s name & phone #, if applicable
Please enter a valid phone number.
Is the child exposed to any other languages in the home, besides English?
Yes
No
What language is spoken to the child in the home?
What other language(s) is your child exposed to:
What language is spoken to the child at school (if school-aged)?
How many years has he/she been in school?
Which language does your child seem to understand the best?
Which language does your child seem to speak the best?
Does your child follow simple directions in English?
Yes
No
Does your child follow simple directions in another language?
Yes
No
Does your child speak in phrases/sentences in English?
Yes
No
Does your child speak in phrases/sentences in the other language?
Yes
No
What language does he/she use with siblings?
In what language does he/she prefer to watch TV?
Does the caregiver, speak English?
Yes
No
Do you have any concerns about the child’s feeding/swallowing?
Yes
No
What are your current feeding concerns?
Was your child premature?
Yes
No
How early was he/she born?
Does your child currently have a G-tube, NG tube or Trach?
Yes
No
Does your child take eat or drink anything by mouth?
Yes
No
What type of items does your child eat and drink?
Do you have concerns about your child choking?
Yes
No
Has the child had feeding therapy in the past?
Yes
No
From where?
Has your child ever had a Modified Barium Swallow Study (MBSS)?
Yes
No
Approximately when was it done?
Do you have a copy of the results?
If so, please give those results to your therapist at the evaluation.
Name of person completing this form
*
First Name
Last Name
Relationship to this child
*
Your phone #
Please enter a valid phone number.
Any additional information you would like to share?
In what area are you looking to receive services
Ex: DFW (Dallas, Ft. Worth, Frisco, Garland, Plano, et.)
Submit
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