Intensive Therapy Registration Form

Patient Name

First NameLast Name

Date of Birth

Date

Parent/Guardian Name

First NameLast Name

Phone Number

Please enter a valid phone number.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Care Provider Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Specialty Care Provider Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Program Description: Our intensive program plan is set up based on a child’s individual needs. The program is 3 weeks in duration with 2-3 hours of combined therapies per day. Please note which services you would like:

Physical Therapy: How many days per week?

Occupational Therapy: How many days per week?

Speech Therapy: How many days per week?

Feeding Therapy for limited diet, picky eater, sensory concerns; How many days per week?

Feeding Therapy for dysphagia, swallowing, medical feeding issues; How many days per week?

Which dates are you interested in? Option 1:

Which dates are you interested in? Option 2:

Which dates are you interested in? Option 3:

What time of day is best for your child?

Please describe your child's medical needs.

Please describe your goals for the program:

Method of Payment: Would you like to bill your insurance or use another method of payment for the program duration?

If you would like to use insurance benefits, please complete the section below. If not using insurance, 50% of payment for the program will be due thirty days prior to beginning the program. Balance will be collected at the conclusion of the program.

Insurance Provider

Subscriber Name

Insurance Plan ID Number

Group Number

Secondary Insurance

Subscriber Name

Insurance Plan ID Number

Group Number

Thank you for your interest in our Intensive Therapy program. If you have any additional questions, please contact Kendra at kendra@gsgtherapy.com. Please have your referring provider send a referral for Intensive Therapy to Abby, our Referrals Coordinator, by fax 423-717-5543. Any additional questions for the referral can be sent to Abby at referrals@gsgtherapy.com.

If the times listed above do not work for your plans in 2025, please email us so that we can check the schedule for availability. We look forward to seeing you soon!

Keep Growing!

GSG Staff