Impact Pediatric Therapy and Lactation Support

Impact Pediatric Therapy and Lactation Support Send Message

Your info

First name

Last name

Phone

Name you go by

Date of birth

Do you have additional concerns for another child(ren)? If so, please include their name, date of birth and concern or serivce you are seeking.

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Client's info

Is the client a minor?

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First name

Last name

Phone

Name you go by

Date of birth

Do you have additional concerns for another child(ren)? If so, please include their name, date of birth and concern or serivce you are seeking.

Limited to 600 characters

Reason for care

What type of service are you looking for?

Articulation/Phonological Disorders Childhood Apraxia of Speech Feeding/Picky Eaters Oral Motor Dysfyunction Myofunctional Therapy Pre/Post Therapy for Tongue Tie Releases Expressive/Receptive Language Disorders “Late Talkers” Early Motor Skills (Physical Therapy) Physical, Cognitive, and Sensory Support (Occupational Therapy) Lactation Counseling and Support Group Lactation Class Other

Administrative

Referral source

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Billing & Payment

Insurance details

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Insurance card upload

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Client Preferences

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

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What are good days and times for a therapist to contact you?

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.