Farfalla Integrative Health - New client appointment request for occupational therapy and/or myofascial release

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Thank you for your interest in working with Farfalla Integrative Health.

Please fill out the information below so we can start the process to schedule your initial appointment. All information is confidential.

Farfalla Integrative Health is licensed to provide occupational therapy and myofascial release services to residents of Pennsylvania and New Jersey only. If you live in another state, please do not fill out this form.

If you have Medicare or Medicaid, please do not fill out this form as we cannot accept Medicare or Medicaid beneficiaries as clients because of federal law restrictions.

My insurance is Medicare or Medicaid. *

Yes (If yes, please do not continue with the form. We are unable to legally provide services to you.)

I consent to receive email communications from Christine McDevitt at Farfalla Integrative Health LLC for the purpose of responding to my request for services. I understand that checking "yes" is the legal equivalent of my manual signature.
*

Yes

No (If you check no, we will be unable to email you with necessary information to set up your appointment. You will need to call 267-579-3574 to set up your services.)

Required

What state do you live in?

Pennsylvania

New Jersey

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Full name *

Email address *

Phone number *

Do we have your permission to leave messages on this phone number if necessary? *

Okay to leave VOICE AND/OR TEXT messages

Okay to leave VOICE messages ONLY

Okay to leave TEXT messages ONLY

Do not leave any messages on this number.

Service you would like to schedule: *

Occupational therapy only

Myofascial release only

Occupational therapy with myofascial release

Required

Briefly describe your reason for seeking services. *

For Pennsylvania residents: A prescription for occupational therapy is required to schedule both OT and myofascial release with Farfalla Integrative Health. This prescription can be written by a licensed physician, physician's assistant, or nurse practitioner.

For New Jersey residents: A prescription is not required for OT or myofascial release services. However, one will likely be required if you plan to submit for out-of-network reimbursement from your insurance company. In this case, we will need a prescription for occupational therapy prior to starting services.

For both states: You are responsible for obtaining this prescription from your doctor's office. The information needed on the prescription and our fax number can be found here. (Scroll down to the "prescription requirements" section.)

I understand that I am responsible for obtaining my prescription to schedule occupational therapy and/or myofascial release sessions.

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Please type today's date. *

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