Therapy Application

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 *

SPEECH THERAPY & OCCUPATIONAL THERAPY APPLICATION

Child & Insurance

Contact Information

Diagnosis & Clinical Documentation

Service Preferences

Review, Consent & Signature

Thank you.