Refer a Child

Click here to download form.

* Please note that ALL fields are required

PATIENT INFORMATION














INSURANCE INFORMATION













TREATMENT INFORMATION


Speech TherapyOccupational TherapyPhysical TherapyMedical Nutrition TherapyFeeding/oral facilitation/dysphagiaLanguage/CognitiveNMES-VitalStim Therapy

ICD/10 Diagnosis:
F90.0 - ADHD predominantly inattentive typeF90.1 - ADHD, predominantly hyperactive typeF84.0 - Autistic DisorderF91.9 - Conduct disorder, unspecifiedG80.0 - Spastic quadriplegic cerebral palsyG80.9 - Cerebral Palsy, unspecifiedR48.1 - AgnosiaR48.2 - ApraxiaR62.0 - Delayed milestone in childhoodF82 - Specific Developmental Disorder of Motor FunctionF81.9 - Developmental disorder of scholastic skills, unspecifiedF89 - Unspecified disorder of psychological developmentR62.50 - Unspecified lack of expected normal physiological development in childhoodF80.1 - Expressive Language DisorderR26.2 - Difficulty in walking, not elsewhere classifiedQ90.9 - Down Syndrome, unspecifiedR26.0 - Ataxic GaitR26.1 - Paralytic GaitR26.89 - Other abnormalities of gait and mobilityR26.9 - Unspecified abnormalities of gait and mobilityR27.0 - Ataxia, unspecifiedR27.8 - Other lack of coordinationR27.9 - Unspecified lack of coordinationQ02 - MicrocephalyF80.2 - Mixed Receptive-Expressive Language DisorderF84.9 - Pervasive developmental disorder, unspecifiedF80.89 - Other developmental disorders of speech & languageR47.02 - DysphasiaR47.81 - Slurred speechR47.89 - Other speech disturbancesQ05.4 - Unspecified Spina Bifida with hydrocephalusM43.6 - Torticollis

PRACTICE INFORMATION












Please answer the quiz to verify you are a human. Thank you.