Public Intake ST OT ABA

Public Intake ST OT ABA

Welcome to the Sunshine Center Pediatric Therapy Automated Client Intake System. Please fill out the form below and a member of our team will contact you to schedule your first appointment. if you have any questions throughout this process, feel free to contact 918-615-6492, Ext 2.

Services Needed*

Speech Therapy

Occupational Therapy

Applied Behavioral Analysis

What is your child needing help with?

Child's Primary Care Physician

Child's First Name *

Child's Last Name *

Child's Date of Birth

Gender

Male

Female

Child's Address Info:

Child's Address

City

State

Zip Code

Primary Guardian Info:

Primary Parent/Guardian *

Relationship to Child *

Parent/Guardian Cell Phone *

Consent to Receive SMS Notifications

By checking this box, I consent to receive SMS notifications regarding my child's appointments.I understand that message and data rates may apply, depending on my mobile plan.I can opt out of this service at any time by replying "STOP" to any message received.

I prefer phone calls

Primary Insurance Info:

Primary Insurance

Primary Insurance Member Name

Date of Birth

Member #

Group #

Customer Service Phone #

Secondary Insurance Info:

Secondary Insurance

Primary Insurance Member Name

Date of Birth

Member #

Group #

Customer Service Phone #