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 firstname.lastname@example.org. 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:
Parent Questionnaire BUT if the PT referral is for an injury, please use this form:
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.