Programe una proyección gratuita

(Valor de $80)

Programe una evaluación gratuita para comprender mejor el nivel de desarrollo de su hijo. Pasará algún tiempo con uno de nuestros terapeutas altamente capacitados y sus preguntas e inquietudes serán respondidas. Al final de la evaluación de 30 minutos, se irá con recomendaciones personalizadas para apoyar el desarrollo continuo de su hijo en el hogar. Además, si su hijo requiere un mayor nivel de apoyo, nuestros terapeutas pueden ayudarlo a tomar una decisión más informada sobre las evaluaciones u otras referencias.

Pre-Screening Information

Completing this form will alert our staff that you would like to schedule a free screening. One of our office staff will be in contact to set up a time. Free screenings can be scheduled between the hours of 7:30am - 3:00pm, based on therapist availability. Completing this form will help our therapists prepare for the screening.

Child's Name*
First
*
Last
Date of Birth*
MM slash DD slash YYYY
Age*
Child's preferred pronouns*
How did you hear about us?*
Type of Insurance:*
Emerge Pediatric Therapy is an in-network provider for all Tricare insurance plans, Health Choice, and NC Medicaid. We will bill these plans directly and collect any co-payments and deductibles as necessary. We are out-of-network for private commercial insurance plans. Please visit our FAQ page on our website to learn more: https://www.emergepediatrictherapy.com/about-us/faq/
Caregiver Name (First, Last)*
Email*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
If referred by a friend or family member, who referred you for a free screening?
What are your concerns for your child (at home, school, etc.)?*
What have professionals told you about your child?*
Is your child currently receiving any additional services or have they received them in the past? If so, please explain.*
Are there specific days and times that you are available to schedule the screening? If so please list below.