Consent form for OT/PT/Speech

Services Seeking

Speech & Language

Occupational Therapy

Physical Therapy

*A screening is a preliminary observation (15-20 minutes) based on professional recommendations. There are no assessments done and no paperwork. We will call you with results, at which point you can decide whether to move forward with a full evaluation.

*An evaluation follows a standardized assessment, and you will receive a copy of the report upon completion.

*We accept BCBS, United Healthcare/UMR, and Soonercare/Medicaid insurances.

Child’s name *

Date of birth *

Parent/Guardian Name: *

Home address *

Cell phone number *

Best time to reach you (circle one)

Email address *

Pediatrician Name

Insurance

Has your child received therapy services in the last year?

Days/times your child is at this facility

(parent/guardian name), grant permission for

(child’s name) to receive a screening for therapy services at

(school/daycare name).

Parent/Guardian Signature

Clear

Date

Fundamental Therapy Solutions
3312 S. Peoria Ave., Tulsa, OK 74105
Phone: (918) 400-0089 Fax: (539) 430-0051
[email protected]

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.