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 our Referral Coordinator at jzmreferrals@gmail.com.  Once the paperwork has been received, our Referral Coordinator 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

     Text Disclosure

     Statement of Financial Responsibility

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

                           Injury Parent Questionnaire

Then, 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

     If there are feeding concerns, please also fill out: the Feeding Questionnaire

for Speech Therapy:              the Speech Therapy Addendum

          ***If your child is less than 3 years old, please also fill out:

                                                   the Expressive Language Checklist

    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.