Download and complete these forms before your first visit to help us provide the best care for your child.
Everything in one packet (7 pages): patient information, developmental history, services agreement, consent for treatment, financial policy, HIPAA notice, authorization to release records, and session attendance log.
Download PDFNeed a specific form? Download individually below.
Authorization for occupational therapy evaluation and treatment services.
DownloadPayment policy, fee schedule, cancellation policy, and Step Up for Students information.
DownloadInformation about how we protect and use your health information.
DownloadPermission to share records with schools, doctors, or other providers.
DownloadEstimate of expected costs for services (required by No Surprises Act for self-pay patients).
DownloadForms used throughout your child's therapy.
Monthly log for tracking therapy sessions. Parents sign to verify attendance. Required for Step Up for Students scholarship documentation.
Download PDFInsurance reimbursement and service agreement documents.
For families seeking out-of-network insurance reimbursement. Includes ICD-10 diagnosis codes, CPT procedure codes, and itemized services. Submit to your insurance provider with your out-of-network claim.
DownloadProvider contract outlining scope of services, fees, cancellation policy, Step Up billing, and parent/guardian rights and responsibilities.
DownloadHave questions about the forms?
Contact Us