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For Parents

For Physicians

New Client Form

Complete a few easy steps below and we will be in touch soon.

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Parent / Caregiver

Parent / Caregiver First Name **

Parent / Caregiver Last Name **

Phone # **

E-mail **

Address*

City*

State*

Zip*

Client

Patient First Name **

Patient Last Name **

Child's Date of Birth **

Preferred State*

Florida - Preferred Location*

North Carolina - Preferred Location*

Texas - Preferred Location*

Virginia - Preferred Location*

Please list preferred days/hours:

Primary Insurance **

Primary Language **

Full Name of Insured **

Relationship to Client **

Date*

Member ID:

Desired Therapies (check all that apply)*

ABA

Diagnostic

Speech

Home Health/PDN

Occupational

PPEC

Physical

Music & Nutrition

How did you hear about MySpot?*

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Our Locations

Find the services you need closest to you.

Call us: 833-543-7768

Referrals welcomed.

Physicians and care providers are the foundation of our relationship. We are here for you and your patients to provide pediatric therapy services including Speech, Physical, Occupational, ABA and Home Health as part of their comprehensive care plan.

Call or fax us: 833-543-7768

For Home Health patients in Texas fax us at: 832-539-1633

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