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Online Forms - Therapies 4 Kids

New Client Eligibility Form

Initial Client and Insurance Information Form. Please fill the form below (fields marked with an * are mandatory) to send your request to our service.

Client Information

First Name*:

Last Name*:

Date of Birth*:

Gender:

Male

Female

Address line 1*:

Address line 2:

Zip Code*:

State*:

City*:

Country*:

Diagnosis*:

Availability*:

Morning, before 12pm

Mid-day, 10am - 2pm

Afternoon, after 2pm

Afternoon, after 4pm

Notes Regarding Availability:

Primary Care Physician*:

Physician Phone Number:

What services do you seek from us?

Physical Therapy

Occupational Therapy

Speech Therapy

ABA Therapy

Chiropractic

Psychiatric Services

Parent/Caregiver Information

First Name*:

Last Name*:

Date of Birth:

Gender:

Male

Female

Relationship to Client*:

Home Phone:

Cell Phone:

Work Phone:

E-mail*:

How Did You Hear About Us?*

Insurance Information

Primary Insurance:

Use Client & Parent/Guardian's Information

Subscriber Name:

Date of Birth:

Address Line 1:

Address line 2:

Zip Code:

State:

City:

Country:

ID Number:

Group Number:

Attach Files

Front of Insurance Card:

Back of Insurance Card:

Autism Diagnosis Report:

Doctor Referral:

IEP:

Contact us

2010 NW 150th Ave Ste. 120
Pembroke Pines,
Florida 33028
MAP

Phone: 1-954-719-6280

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• HIPAA Privacy Rule

Contact us

1311 N Palm Ave
Pembroke Pines,
Florida 33024
MAP

Phone: 1-954-719-6280

• HIPAA Privacy Rule

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