Request a service

Childs Name

Childs Age

+ -

Parent/Guardian Name

Phone Number

Email

Childs Doctor-Primary Care Physician

Service you are requesting

Physical Therapy Treatment Session

Occupational Therapy Treatment Session

Physical Therapy Screen

Occupational Therapy Screen

Physical Therapy Evaluation

Occupational Therapy Evaluation

Was the child approved for services through the DOE?

Yes

No

What are your concerns

How did you hear about us?

A friend

Social Media

My child's doctor

Sign

Internet Search

My Childs School

other

Confident Kidz at The Kidz Lounge