Please complete the form below to contact Adaptations regarding a benefits check, free screening or to inquire about scheduling services. This is a HIPAA compliant, encrypted form.
Caregiver's Name
*
Child's Name
*
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you a new or returning client
New
Returning
Looking For
*
Screening(s)
Evaluation(s)
Ongoing Service(s)
Do you have an evaluation that was completed in the last 6 months?
Yes
No
Please upload your recent evaluation(s) below
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Cancel
of
Where are you interested in having services?
*
Lake County
Cook County
DuPage County
McHenry County
Virtual in Illinois
Service Types Available in Lake County
*
Occupational Therapy
Speech Therapy
Physical Therapy
Developmental Therapy
Infant Massage Instruction
Service Types Available in Cook County
*
Occupational Therapy
Service Types Available in DuPage County
*
Occupational Therapy
Infant Massage Instruction
Service Types Available in McHenry County
*
Occupational Therapy
Physical Therapy
Developmental Therapy
Infant Massage Instruction
Service Types Available Virtually throughout Illinois
*
Occupational Therapy
Speech Therapy
Developmental Therapy
Infant Massage Instruction
Physical Therapy
If you have questions about the cost of services or insurance coverage, we can provide a free benefits check.
*
I would like a benefits check
Not at this time
If you are requesting an evaluation or ongoing services, we require insurance information.
Name of Policy Holder
*
Policy Holder Date of Birth
*
-
Month
-
Day
Year
Date
Upload pictures of the front and back of your insurance card here. If you are unable to do so, fill out the 3 fields below.
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Drag and drop files here
Choose a file
Cancel
of
Insurance Company
Group Number
Member ID
Submit
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