Call Us Today
678.749.7600
Pay My Bill
Patient Portal
About
Our Story
Our Location
Our Team
Our Facility
Frequently Asked Questions
Services
Physical Therapy
Occupational Therapy
Speech & Language Therapy
Neurotherapy & Biofeedback
Psychological Evaluation
Group Offerings
What We Treat
Resources
Trusted Community Partners
Insurance and Funding
Blog
Mental Health Topics
Parent Help Topics
Speech Topics
Contact
Make an Appointment
Pay My Bill
Patient Portal
Toggle Menu
Make an
Appointment
Patient Name
*
First
Last
Email
*
Phone
*
Date of Birth
*
MM
DD
YYYY
Contact Preference
Contact Preference
Phone
Email
Will health insurance be used?
Yes
No
Primary Insurer
Primary Insurer ID#
Primary Insurer GRP#
Secondary Insurer
Secondary Insurer ID#
Secondary Insurer GRP#
If the patient is under 18 years of age, do you have custody/guardianship?
Yes
No
Select a Service
Select a Service
qEEG Brainmapping
Splinting, Orthotics, and Casts
Sensory Integration & Astronaut
Neurotherapy & Biofeedback
Interactive
Neurofeedback
Play Oriented
Parent Effectiveness
Group & Family
Individual
Speech & Language
Physical
Occupational
Psychotherapy
Psychological
Allied Health
If you're looking for a different service, please use the space below to specify.
Main Referral Question
Has the patient recently tried to commit suicide?
Yes
No
Has the patient recently been involved in a head injury?
Yes
No
Has the patient recently displayed dangerously violent or aggressive behaviors toward others?
Yes
No
Has the patient recently been in inpatient care, if so, why?
Does Patient have an IEP?
Yes
No
Patient's Preferred Pronouns
How did you hear about us?
*
Email
This field is for validation purposes and should be left unchanged.
