February 26, 2015

Make a Referral

If you are interested in Physical Therapy, Occupational Therapy, and/or Speech Therapy, you have two options to send your information to us:

 

      1.   Print the Referral form out and then fax or email back to Therapy Talk:

REFERRAL FORM

OR

      2.   Complete the information below

 

Client Information

Type of Therapy

Client's Name

Client's Date of Birth

Parent's Name

Phone Number

Email Address

Patient's Address

City

State

Zip Code

Physician's Name

Physician's Practice Name

Physician's Practice Phone Number

Medical Diagnosis (if known)

Insurance Information

Name of Insurance Company

Policy Holder's Name

Policy Holder's Date of Birth

Group #

Identification #/Member #

Claims Address

City

State

Zip Code

 

IMG_2896