TidalHealth Request an Appointment

Request an Appointment
Seeking an initial appointment and evaluation for your child? Fill out this form below and we will get back to you within 7-10 business days. Please complete information to the best of your ability. Missing or inacurate information may delay our ability to help.
Child's Name*

First NameLast Name
Parent or Guardian's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Gender*

FemaleMale
Home Phone

Area CodePhone Number
Mobile Phone

Area CodePhone Number
Email*
example@example.com
How do you prefer to be contacted to set up an appointment?

PhoneTextEmail
When is the best time to call?
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Care Physician Name*
Primary Care Physician Practice*
Primary Care Physician Phone Number

Area CodePhone Number
Insurance Company*
ID #
Group #
Policy Holder Name

First NameLast Name
Policy Holder D.O.B.

MonthDayYear
Date
Insurance Card

To speed up processing of your appointment request and ensure accurate insurance coverage information, we ask for an image of your insurance card. If this is not possible now, we will scan your insurance info during your evaluation.
Upload Image of your Insurance Card (optional)

Browse Files

Cancelof
Take Photo of Insurance Card (optional)
Requesting appointment for (check all that apply)*

ABAOccupational TherapySpeech Therapy
How did you hear about us?

GoogleFacebook/InstagramWord of MouthPediatrician/DoctorOther
Concerns (Check all that apply and add any additional comments)*

AnxietyAutismADD/ADHDBehavioralCoordinationSensory Integration Disorder (SID)FeedingFine MotorGross MotorTorticollisOrthopedic InjuryArticulationFluency/StutteringVoiceExpression/Receptive LanguageOther
Comments
Currently receiving services elsewhere?

YesNo
If yes, where?
Frequency
School Name
Does your child have an IEP?

YesNo
If therapy is recommended for your child, they will be placed on our permanent schedule to come during the same days/hours every week (or every other week depending on evaluation recommendations). To help us plan for that, please indicate below when you are available for a weekly appointment. If you are requesting an evaluation for ABA therapy, please keep in mind that ABA is an intensive therapy that requires 10-40 hours/week of direct care.
Availability for weekly appointments (check all that apply)*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Available times (check all that apply)*

MorningEarly AfternoonLate Afternoon
Which location(s) do you prefer? (Check all that apply)*

Millsboro, DESalisbury, MD
Any specific times or scheduling comments?
Should be Empty: