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Equine and Aquatic ST OT PT
New Client Forms
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Name of Child
First Name *
Last Name *
Age of Child (Required)
Address
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
Parent/Guardian
First Name *
Last Name *
Phone (Required)
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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)