SPEECH THERAPY & OCCUPATIONAL THERAPY APPLICATION

Please complete this secure application form. We will review the information provided and contact you as soon as possible via email.

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Secure & Confidential Form Your information is protected and handled securely.

* Fields marked with an asterisk are required.

Child & Insurance

Child's First Name *

Child's Last Name *

DOB * Use MM/DD/YYYY

Insurance name *

Insurance ID *

Is your child enrolled in Step Up for Students? *

YesNo

Choose Yes if your child is currently enrolled in Step Up for Students.

Step Up for Students Student ID Step Up for Students Student ID is required when enrollment is Yes.

Contact Information

Address *

City *

State *

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 772-672-0897. To stop receiving messages at any time, reply STOP.

Diagnosis & Clinical Documentation

Child's diagnosis (if applicable)

I have the doctor referral for ST and/or OT *

YesNo

My child is transferring from another agency *

YesNo

If yes, I have a discharge summary from my previous agency *

YesNo

Answer this question even if your child is not transferring.

My child needs a Speech Generating Device (SGD) because they have difficulty speaking and need another way to communicate more independently. *

YesNoI don't know

Service Preferences

I prefer services at *

Clinic (In-person)Telehealth (online)

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.

I'm also interested in enrolling my child in the following services:

Home Education Instructional Program Tutoring. Math and Language Arts After school specialized program 4pm-6pm Summer Camp - Specialized program Not interested at this time

Choose all that apply. Not interested at this time cannot be combined with another option.

Review, Consent & Signature

Parent / Legal Guardian Full Name *

Additional comments

Electronic Signature *

I 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.

Thank you.

Your Speech Therapy & Occupational Therapy application has been sent successfully.

Bilingual Key Therapy · Contact

Pediatric Therapy in Port St. Lucie

Bilingual Key Therapy is a pediatric clinic located in Port St. Lucie, Florida, providing Speech-Language Therapy, Feeding Therapy, Occupational Therapy, and Early Intervention services for children from birth through 18 years old.

We offer therapy in English and/or Spanish and support children with autism, development delays, ADHD, sensory integration challenges, genetic disorders, cerebral palsy, traumatic brain injury, and other communication or developmental needs.

Non-clinical services include Spanish immersion groups, Spanish tutoring, accent reduction, and related language support services.

Speech-Language Therapy

Feeding Therapy

Occupational Therapy

Early Intervention

Spanish Tutoring

Accent Reduction

Contact Information

Contact Elizabeth Barrios, MS, CCC-SLP, for more information about pediatric therapy services.

Elizabeth Barrios, MS, CCC-SLP
Speech-Language Pathologist Phone: 1 (772) 672-0897 Fax: 1 (772) 673-3225 Bilingual Key Therapy
1631 St Lucie W Blvd, Suite 208
Port St. Lucie, FL 34986

Call Now

Elizabeth Barrios MS, CCC-SLP

Phone: 772-672-0897

Fax: 772-673-3225

Address:
1631 St Lucie W Blvd, Suite 208
Port St. Lucie, FL 34986

Staff Email

Services

Speech-Language Therapy
Occupational Therapy
Feeding Therapy
Early Intervention
Spanish Immersion Camp
Spanish Tutoring
Accent Reduction

Programs & Partners

Important Information

Bilingual Key Therapy provides speech-language therapy, occupational therapy, feeding therapy, educational support, and bilingual family-centered services in Port St. Lucie and the Treasure Coast.

Location:
Port St. Lucie, Florida

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