OT Self Referral Form

SELF REFERRAL FORM

Welcome to Recreate Pathways, we are so glad you are here! The first step to services is to fill out this self referral form.
Date*

MonthDayYear
Date
CONTACT INFORMATION
Legal Name*
Preferred Name (if different)
Pronouns *
Email*
example@example.com
Phone Number
Please enter a valid phone number.
Why are you seeking Occupational Therapy?*
WHAT TYPES OF SERVICES ARE YOU INTERESTED IN?
Select all areas that you are seeking support in*

Sensory ProcessingEmotional RegulationInterpersonal Problem SolvingDaily RoutinesWeekly SchedulingSelf-Advocacy in EmploymentOccupational Therapy EvaluationTeam ConsultationOther
At RCP we offer individual, small closed group, and workshop based services; which types of services are you seeking?*

1:1 / Individual OTSmall GroupWorkshopAnyNot Sure
Please list any support needs and preferences you have about how you receive services at Recreate Pathways
AVAILABILITY

Optional, but SUPER helpful for estimating timelines and OT availability.
We have a high demand for our services at Recreate Pathways and we are always working to find innovative ways to meet the need for Occupational Therapy for Neurodivergent Adults.

Our individual services open up with specific time slots, and knowing when someone is available helps us give you the most accurate picture of when we will be able to meet your needs.

Please select ALL of the times that work for your schedule to meet weekly without missing appointments.

Select the days of the week and times you are available for weekly OT appointments. Note: if you are filling this on a cell phone scroll to the left inside this table to see the rest of the days of the week.

	Monday	Tuesday	Wednesday	Thursday	Friday
9a -11a
11a - 1p
1p- 3p
3p-5p
5p-7p

List any availability notes here such as known conflicts with above availability, vacations, etc.
ACKNOWLEDGMENT OF OUT OF NETWORK SERVICES
I understand that Recreate Pathways is out of network with ALL insurance, all services are private pay require a card on file.
I understand that Recreate Pathways will not directly interact with any insurance provider, but they provide me super bills I can submit to insurance myself if I would like.
Should be Empty:

SELF REFERRAL FORM

CONTACT INFORMATION

WHAT TYPES OF SERVICES ARE YOU INTERESTED IN?

AVAILABILITY

ACKNOWLEDGMENT OF OUT OF NETWORK SERVICES