SPEECH THERAPY & OCCUPATIONAL THERAPY APPLICATIONPlease complete this secure application form. We will review the information provided and contact you as soon as possible via email. 🔒 Secure & Confidential Form Your information is protected and handled securely.12345* Fields marked with an asterisk are required. Child & Insurance Child's name * DOB * Use MM/DD/YYYY Insurance name * Insurance ID * Step Up Student ID *YesNo Choose Yes only if your child has a Step Up Student ID. Step Up Student ID Step Up Student ID is required when Step Up is Yes. NextContact Information Address * City * State * Select stateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDistrict of Columbia Zip Code * Email * Phone Number * By selecting this option, you agree to receive text messages from Bilingual Key Therapy. The number of messages may vary, and standard message and data charges could apply. Your phone number will only be used for SMS communications and will not be sold or shared with any third parties or affiliates for marketing. For help, text HELP to 772-327-1731. To stop receiving messages at any time, reply STOP. Back NextDiagnosis & Clinical Documentation Child's diagnosis (if applicable) I have the doctor referral for ST and/or OT *YesNoMy child is transferring from another agency *YesNoIf yes, I have a discharge letter *YesNoAnswer this question even if your child is not transferring. Back NextService Preferences I prefer services at *ClinicSchoolTelehealth Choose one option. My child needs * Speech therapy Occupational therapy Feeding Therapy Choose one or more therapy services. I’m looking for services *In the morningAfternoon Choose one option. My child is enrolled in *Public schoolPrivate schoolDaycare Choose one option. My child is in grade My child is currently receiving * ST OT PT Feeding therapy Other Therapy Select at least one therapy above. Use Other Therapy only if needed. Back Next Would you also be interested in the following services? Check all that apply. AAC Evaluation for individuals with complex communication needs to obtain Speech Generating Devices that improve expression and independence. Part-time Tutoring Services for children with unique abilities to help build confidence, skills, and joy in learning. Specialized Summer Education Program that offers therapeutic integration, ST, OT, ABA strategies, plus music, drama, arts & crafts, sensory play, dance, movement, and life skills. After-School Education Program — a supportive, structured, and joyful program that builds academic skills, confidence, independence, and motivation for learners with unique abilities. Optional. You may choose one, several, or leave this blank.Review, Consent & Signature Parent / Legal Guardian Full Name * Additional comments Electronic Signature * Clear SignatureI certify that the information provided is true and accurate to the best of my knowledge, and I consent to be contacted regarding this Speech Therapy & Occupational Therapy application. I agree and authorize this electronic submission. Back Submit ApplicationThank you.Your Speech Therapy & Occupational Therapy application has been sent successfully.
