Play OnWords Initial Contact Form

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Thank you for reaching out to POW! Shortly after completing this form, you will receive a "Welcome" email from our patient portal software: PlayOnWords.Theraplatform.com. Please follow the directions to create a password, log in, and complete our intake form. Once the intake forms are completed, we schedule the initial appointment with the appropriate specialist. Should you have any questions, please do not hesitate to contact us: hello@playonwordsvi.com or 340-727-7529 (text, WhatsApp, voice).

Email *

Does your child currently carry a diagnosis? *

Developmental Delay

Autism Spectrum Disorder

ADD / ADHD

Dyslexia

Deaf / Hard of Hearing

Down Syndrome

Currently in testing

None

Other:

Required

Patient's Name (First, Last) *

Patient's Birthdate *

YYYY

Legal Guardian's Name and Relationship to Child: *

Guardian Phone Number:
*

Guardian Email: *

General Concerns:

Speech-Language / Communication

Behavior

Balance / Coordination

Fine Motor / Handwriting

Eating / Feeding / Breastfeeding

Self-Care / Daily Skills (e.g., tying shoes, brushing teeth)

I'm not sure

Other:

Health Insurance

We accept almost all health insurance plans offered in the USVI: Cigna, MAP, MAPFRE, UHC, Aetna International, ELAN, Triple S, UBS. If your company is not listed, please still provide your insurance information.

Do you have active health insurance? *

Yes

I'm not sure

If you have health insurance, list the name of the company and membership number:

How did you hear about us? *

Submit

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