Enrollment

Enroll Yor Child

If you are interested in acquiring information about our therapy services, please fill out the Intake Referral Form. Once finished, click on the submit button below. We will contact you once it is received.

Intake Referral Form

Type of therapy service requested: (check all that apply)

Physical Therapy	Speech Therapy
Occupational Therapy	Respiratory Therapy

Patient Name

Date of Birth

Sex

Male Female

Parent/ Guardian Name

Home Address

City

Home Phone

Cellular Phone

Work Phone

Email Address

Case Worker Name

Primary Care Physician’s Name

Comments:

Do You Qualify?

Individuals may qualify for therapy services if any of the following are noted:

• difficulty with dressing
• difficulty with feeding
• difficulty with basic concepts
• poor handwriting
• difficulty standing, walking, running
• loss of balance / incoordination
• muscular weakness
• poor vocabulary
• excessive drooling
• difficulty chewing / swallowing
• difficulty breathing

Kids Therapy

	B & V Thera-Pro Associates, Corp. Office 786-208-2814 or 786-208-2813 • Fax 305-228-6251 Contact Us by Email: theraproassociates@netzero.net Serving the Miami-Dade County Area
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