My Child Needs Therapy

Horizon Pediatric Therapy offers Physical, Speech, Occupational and Music Therapy. If you are looking for a therapist please take a few minutes to fill out this form. After completion it will be forwarded to our office and we will review the information. We will notify you if we have a therapist available to treat your child. Each therapist has different areas of expertise and availability. Schedules and openings do change frequently. If we do not have any available therapists we will keep your child's information on file for 60 days. If you are still looking for a therapist after 60 days please fill out this form again.

SERVICES YOU ARE LOOKING FOR:

Speech Therapy

Evaluation
In Home
On-going Therapy
West Clinic
Not Sure
East Clinic

No Preference

Occupational Therapy

Evaluation
In Home
On-going Therapy
West Clinic
Not Sure
East Clinic

No Preference

Physical Therapy

Evaluation
In Home
On-going Therapy
West Clinic
Not Sure
East Clinic

No Preference

Music Therapy

In Home West Clinic East Clinic No Preference

Is your child currently receiving any other services through Horizon Pediatric Therapy, Inc.?

Yes No

Child's First Name:

Child's Last Name:

Child's Age:

Date of Birth:

Parent's First Name:

Parent's Last Name:

Phone Number 1:

Phone Number 2:

Email Address:

Confirm Email Address:

Home Address:

City:	State: Zip Code:

Nearest Busy Crossroad

Describe your availability for therapy in detail (remember to include school schedules, nap times, other therapy appointments, etc.):

Please describe your primary areas of concerns and please list all diagnoses:

Are you looking for a therapist with any special skills or training? Please describe:

Do you have Family Health Insurance?

Yes No

Has your child qualified for services through the Division of Developmental Disabilities?

Yes No Not Sure

Other Comments or Concerns:

Please enter the exact text that appears in the image below: