Service Request Form

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Please complete this form if you are interested in receiving pediatric therapy services from Team Therapy. Our clinic is located at 1710 Richland St, Suite B.

If you have additional questions, please contact us at (803) 253-6223 or lisa@teamtherapysc.com.

Email *

Patient Name *

Patient Date of Birth *

YYYY

Parent Name(s) *

Contact Email *

Contact Cell Phone # *

Which service(s) are you interested in? (select all that apply) *

Speech Therapy

Feeding Therapy

Occupational Therapy (OT)

Physical Therapy (PT)

Required

What type of insurance do you have? *

Team Therapy clinic hours:

Monday-Thursday 8am-6pm and

Friday 8am-12pm

What is your availability for receiving services? *

Did you receive a referral?

Yes

Other:

Clear selection

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