Rehabilitative Therapy Referral
Please complete this form and attached a current prescription for therapy services. Please note that referrals cannot be processed until both the Referral for Therapy Services form and prescription are received. Please contact Shae Peak, Director of Medical Rehabilitative Therapy, with any questions at 803-212-8971. We look forward to working with you!
Service (s) Requested
Occupational Therapy
Physical Therapy
Speech Therapy
BabyNet Eligible:
Yes
No
Hospice Eligible:
Yes
No
Child Name
First Name
Last Name
DOB
-
Month
-
Day
Year
Child's Date of Birth
Gender:
Male
Female
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Therapy at home:
Yes
No
If no, address of visit location:
Guardian Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Interpreter Required:
Yes
No
If Yes, Interpreter Name and Phone Number:
Primary Physician:
Physician Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Physician Phone Number
-
Area Code
Phone Number
Physician Fax:
-
Area Code
Phone Number
Insurance Permitted:
Yes
No
Insurance Coverage: (Check all that apply)
Private Insurance
Medicaid
BabyNet
Insurance Company:
Policy Number:
Policy Holder:
Policy Holder DOB:
-
Month
-
Day
Year
Date
Medicaid Number
MCO
Yes
No
If yes, MCO Name
Has this child been previously evaluated
Yes
No
If yes, what was the date of the most recent evaluation: (please include a copy of the evaluation)
-
Month
-
Day
Year
Date
Early Interventionist (EI):
EI Agency:
EI Phone:
-
Area Code
Phone Number
EI Fax:
-
Area Code
Phone Number
EI Email:
example@example.com
EI Signature:
Additional Questions:
Have you already contacted an Easterseals Therapist? If yes, who did you speak with?
Please give a brief explanation if you cannot provide a current prescription.
Date of Referral:
-
Month
-
Day
Year
Date
Upload Prescription
Browse Files
Cancel
of
Prescription Included:
Yes
No
Submit
Should be Empty: