Step 1: Intake Questionnaire

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This is your first step! Please fill out this form in its entirety and we will contact you as soon as we have availability in your preferred time frames.

Once you have completed this questionnaire, the full intake packet will be emailed to you. Completing this packet prior to us calling you will greatly speed up the process of scheduling your appointment. Please be aware that once you receive the link for this paperwork, it will expire in 48 hours. If you have any further questions, please email intakes@totstoteenstherapy.com. We look forward to your family joining the Tots family!

Email *

Child's (PATIENT) Full Name *

Which service are you inquiring about: (please check all that apply) *

Occupational Therapy

Physical Therapy

Speech Therapy

Feeding Therapy (Picky Eating, Problem Feeding, Chewing, Swallowing, Texture Concerns)

Telehealth Services

Required

Which location are you interested in (check all that apply) *

12581 Milstead Way Suite 302 Woodbridge, VA 22192

3850 Fettler Park Dr Suite 103 Dumfries 22025

Telehealth Services

Required

Child's Date of Birth *

Please note that if your child is under 3 years of age (and you live in Prince William County), they are eligible receive services through Virginia Early Intervention Services. Please call (703) 792-7879 for more information.

YYYY

Child's Gender *

Male

Female

Required

Insurance (We are in-network providers for BCBS FEP and PPO plans and Tricare). *

**Please Note: We are NOT In-Network providers with CareFirst, HMO Plans, or Healthkeepers**. **We are not Medicaid-approved providers**

**We do not bill secondary insurance plans**

Tricare Prime

Tricare Select

Anthem Blue Cross Blue Shield FEP

Anthem Blue Cross Blue Shield PPO

Self Pay

CareFirst Blue Cross Blue Shield (We are not in network; this will be self-pay)

Required

Does your child have a current private evaluation? *

Please check below which current (within the last year) evaluations (not school-based) your child already has completed:

Speech Therapy

Occupational Therapy

Physical Therapy

No current evaluations

Required

How did you hear about us? *

Child's Pediatrician *

Availability for appointments:

Check all that apply.

Mornings (8am-noon)

Afternoons (noon-3:30)

After School (3:30-5:30)

Not Available

Monday

Tuesday

Wednesdays

Thursdays

Friday

Date/Time Restrictions *

Please list any date/time restrictions when you are unable to attend sessions.

Flexible Scheduling *

Our flexible scheduling list allows you to be called for appointments during our cancellations while you are awaiting a recurring appointment time. Participation in flex scheduling moves you up on the waitlist. Scheduling preference is given to those who participate in Flex scheduling.

What are your primary concerns? *

Parent/Guardian Name: *

Parent/Guardian Phone Number: *

What city/area do you live? *

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