Established November 1st, 1991 - Improving the quality of life, one child at a time...

Please download and print the appropriate forms below and drop them off at our clinic at your earliest convenience OR email them to us at  Once the paperwork has been received, our Scheduler will contact you to see about setting up the evaluation appointments. 

All new referrals will need the following paperwork filled out:

     Confidential Release of Information

     Parent Questionnaire   BUT   if the PT referral is for an injury, please use this form:

                           Injury/PAIN Parent Questionnaire

Then, depending on the child's age, please fill out ONE of the following:

                           Infant-Toddler: Symptoms Checklist

                           School-Age: Symptoms Checklist

Next, please download and print the appropriate form(s) below, depending on the therapy for  which your child has been referred:

for Physical Therapy:               the Physical Therapy Addendum

for Occupational Therapy:       the Occupational Therapy Addendum

for Speech Therapy:               the Speech Therapy Addendum

    **If your child stutters, please also fill out: the Stuttering Questionnaire.

Thank you for choosing J.Z. Mann Pediatric Therapy for your child's therapy needs!    

NOTE: You must have Acrobat ® Reader ® installed to view the forms.