Therapy Interest & Verification Form
Indie Learning Co. is an independent learning company that believes in nurturing the whole child in an immensely supportive learning environment. Our naturalistic approach to therapy ensures that sessions are person-centered, child-led and respectful of communication and sensory needs. Fill out the below fields to the best of your ability and a member of our team will reach out with next steps!
Insurance Policy Holder Parent/Caregiver Information
Parent/Caregiver Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Policy Holder DOB
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
School Information
Which Indie School location does your child attend or will attend?
*
Please Select
Indie Innovation Center
Indie Palm Laine
Child's Information
Child's Name
*
First Name
Last Name
Child's DOB:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
I am interested in:
*
In-center Speech-Language Therapy
In-center Occupational Therapy
Insurance Benefits Information
Plan Name
*
Member ID
*
Group
*
Health Plan
*
Support Coordinator Name. N/A if not DDD
*
Support Coordinator Email. N/A if not DDD
*
Front of the Insurance Card
*
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Back of the Insurance Card
*
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Submit
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