New Patient Forms

New Patient Information

HIPAA is the Health Insurance Portability and Accountability Act. This packet allows Integrated Rehabilitation Center to work with your child's medical information and must be signed by the legal guardian before starting treatment. You can print the packets here, or come into our office to sign them. 

Prescription Information

Please contact your child's pediatrician to acquire a prescription. If the doctor agrees that your child needs to initiate therapy services, the prescription must include the child's diagnosis along with the ICD-10 Code, and the treatment for corresponding therapy (ex: Occupational Therapy). If you already have a prescription, it must be within the last 60 days. 

New Patient: Occupational, Speech and Physical Therapy

Once you have a HIPAA Packet and a prescription for therapy services, your child is ready for an evaluation. Contact us to schedule an appointment or come by our office.

New Patient: Applied Behavior Analysis

In order for your child to receive ABA therapy, we need the following documents:

• HIPAA Packet
• Prescription
• Comprehensive evaluation, which includes clinical findings, recommendations, and a diagnosis. This can be any of the following:
• Individualized Education Program
• Evaluation by the patient's school district that has determined eligibility for special education
• Diagnostic evaluation that can be conducted by a Child and Adolescent Psychiatrist or Clinical Psychologist
• A letter from your child's primary care provider recommending ABA services (see below for example letter)
• Questionnaire Packet (see below)