Rincon Roots Pediatric Therapy

Rincon Roots Pediatric Therapy Send Message

Your info

First name

Last name

Phone

Child's full name

Child's sex assigned at birth

male female

Child's date of birth

City

State

Administrative

Referral source

Enter how you were referred to our services

Billing & Payment

Health insurance name (if applicable)

Please note: I am currently in the process of becoming an in-network provider with various insurance networks. While I do not bill insurance directly at this moment, you are welcome to submit your information below. I will notify you as soon as your specific plan is accepted.

Client Preferences

Preferred appointment times

Please note: I am currently welcoming new clients for appointments on Mondays and Fridays. If these days do not work for your schedule, please let me know your ideal availability by submitting your preferences below. I will keep your information on file and reach out as soon as alternative days become available.

Morning Afternoon Evening Monday Tuesday Wednesday Thursday Friday

Which appointment type are you looking to schedule?

FREE: 15-minute Phone Consultation (ages 0-18) OR Speech and Language Screening (ages 0-5) $200: 60-minute Comprehensive Speech and Language Evaluation

Reason for care

Please list any current or past services your child has received.

Example: ABA, occupational therapy, psychological, speech at school, etc.

What concern(s) do you have regarding your child's development?

Speech production/clarity Language Stuttering Late talker Social skills Feeding/swallowing Other (e.g., Autism Spectrum Disorder, ADHD, genetic syndromes, etc.)

Provide any details here.

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.