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Teachwell Therapy Interest Form
Please complete the questions below so we can know more about your child and their needs.
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* Indicates required question
Child's First and Last Name
*
Your answer
Child's Age?
*
Your answer
Child's Date of Birth
*
MM
/
DD
/
YYYY
What type of insurance does the child have?
*
Blue Cross/Wellmark
Sanford
Avera
Tricare
Medicaid
Other:
Child's Primary Care Physician?
Your answer
What type of services are you interested in receiving? (check all that apply)
*
Applied Behavioral Analysis (ABA) Therapy
Speech & Language Therapy
Occupational Therapy
Physical Therapy
Sensory Therapy
Talk Tools
Feeding Therapy
Academic Achievement & IQ Testing
Dyslexia Testing
Assistive Technology
Augmentative & Alternative Communication (AAC)
Autism Evaluations (ADOS Assessment)
I am unsure, please contact me
Required
Parent/Guardian's First and Last Name?
*
Your answer
Parent/Guardian's email address?
Your answer
Parent/Guardian's phone number including area code?
Your answer
How do you prefer we contact you? (check all that apply)
Email
Phone Call
Text
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