Call Us Today
678.749.7600
Careers
Events
Pay My Bill
Patient Portal
About
Our Story
Our Location
Our Staff
Our Facility
Frequently Asked Questions
Services
Physical Therapy
Occupational Therapy
Speech & Language Therapy
Neurotherapy & Biofeedback
Psychological Evaluation
Pediatric Feeding Therapy
Group Offerings
What We Treat
Resources
Trusted Community Partners
Insurance and Funding
Blog
Mental Health Topics
Parent Help Topics
Speech Topics
Updates
Contact
Make an Appointment
Pay My Bill
Patient Portal
Toggle Menu
Make an
Appointment
Patient Name
*
First
Last
Email
*
Phone
*
Patient Date of Birth
*
MM
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
YYYY
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Patient Date of Birth
Contact Preference
Contact Preference
Phone
Email
Will health insurance be used?
Yes
No
Primary Insurer
Primary Insurer ID#
Primary Insurer GRP#
Secondary Insurer
Secondary Insurer ID#
Secondary Insurer GRP#
If the patient is under 18 years of age, do you have custody/guardianship?
Yes
No
Select a Service
*
Select a Service
Psychological Evaluation
Counseling / Psychotherapy
qEEG Brain Mapping
Biofeedback / Neurofeedback Therapy
Interactive Metronome Therapy
Parent Effectiveness Training
Group / Family Therapy
Occupational Therapy
Speech & Language Therapy
Physical Therapy
Vocational Training
If you're looking for a different service, please use the space below to specify.
Main Referral Question
Has the patient recently tried to commit suicide?
*
Yes
No
Has the patient recently been involved in a head injury?
Yes
No
Has the patient recently displayed dangerously violent or aggressive behaviors toward others?
Yes
No
Has the patient recently been in inpatient care, if so, why?
Does Patient have an IEP?
Yes
No
Patient's Preferred Pronouns
How did you hear about us?
*
Online Search (Google, Yahoo, etc.)
Social Media (Facebook, Instagram, etc.)
Insurance Provider List
School System
Family / Friend
My Doctor / Therapist / Other Provider
Returning Patient / Family
Trade Show / Conference
Which doctor, therapist or provider referred you?
*
Email
This field is for validation purposes and should be left unchanged.
Δ
