English Forms
To begin therapy services, you may start by completing our Referral Form below. Once we receive the completed form we will contact your child’s primary pediatrician to be signed. After receiving the signed doctor’s order we will contact you to set up the initial evaluation. Please note, it can take up to two weeks to get the doctor’s order signed. In the meantime if you have any questions please don’t hesitate to contact our office at (803) 329-9500.
Printed forms can be faxed to (803) 228-0101 or mailed to 1612 Ebenezer Rd, Suite 101, Rock Hill, SC 29732
- Request for Services Form
- Physician Order Form
- What to Expect during the Evaluation
- How to Use Fusion Patient Portal
- Case History Form
- New Patient Data Form and Financial Policy
- Attendance Policy Form
- Consent to Video-Tape and Photograph Therapy Sessions
- HIPPA Communication Compliance Form
- HIPPA Compliance Form
- Covid-19 In-Person Therapy Waiver
- Intake Forms Packet