New Therapy Inquiry : What We Do : CDT Kids Charity

Name of Child

First Name *

Last Name *

Age of Child (Required)

Address

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

abtcsoxy093w

Parent/Guardian

First Name *

Last Name *

Phone (Required)

Email (Required)

Looking for Therapist(s)

PT
ST
OT
Feeding

Funding Source

Private Pay
ESA
DDD/ALTCS
Private Insurance (We are Out of Network with ALL Insurance companies)

Is your child approved for DDD & ALTCS Services

Yes
No

My Child has received previous therapy

Yes
No

Preferred Day/Time for appointment (Unfortunately ALL after school 3pm or later ST/OT/PT appointments are unavailable) (Required)

Preferred Location? Clinic? Home? If Home list your crossroads (Required)

What days does your child attend School? School Start and End Time? (Required)

DDD Support Coordinator Name/Direct Phone/Email (Required)

Primary Pediatrician/Physician Name and Office Location (Required)

Name of Private Insurance (We are an Out Of Network Provider with ALL Insurances-may go towards deductible depending on coverage if eligible) (Required)

Name of DDD/ALTCS/AHCCCS Insurance (We do not accept AHCCCS unless your child is ALTCS approved) (Required)

Please list previous therapy(s), and location of therapy(s) received (Required)

Tell us a little bit about your child. How does your child communicate? What does their behavior look like on a bad day? (Required)

Any additional information you may want to add (Required)

New Therapy Inquiry

Mailing Address:

Gilbert Pediatric Clinic