Occupational Therapy Interest Form

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Thank you for your interest in pediatric occupational therapy services with Elisabeth Meikle, MS, OTR/L. I am currently on maternity leave through 7/31/2024. Please complete and submit this form, and I will contact you in late July/early August as I return to work. Thank you for your understanding and I look forward to hearing from you.

Your Name:

Your Email Address:

Best Phone Number to Reach You:

Child's Gender:

Male

Female

Non-binary

Other:

Clear selection

Child's Current Age:

Child's Grade (Current or starting this fall if you're completing this during summer):

Child's current school and any support services they are receiving (please use their first initial):

What city do you live in?

Which OT services are you interested in? (select all that apply)

I want to start with an OT evaluation to better understand my child's needs

An OT evaluation and OT sessions, if indicated

My child has recently had an OT evaluation and I'm interested in OT sessions

I know my child needs support and I'm interested in getting started with OT sessions

What led you to seek OT services for your child at this time?

Please describe your goals for your child's participation in an Occupational Therapy evaluation and/or intervention (please use their first initial):

What days/times is your child available for OT sessions?

How did you hear about me?

Please check the box below indicating your understanding that services provided by Elisabeth Meikle, MS, OTR/L are private pay and not billed through insurance.

Yes, I understand.

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