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To start our placement process, please complete this short form.
Your Name*
First Last

Email*

Who are you seeking services for?
- A Child
- An Adult

I am looking for ...*
- Speech Therapy
- Physical Therapy
- Occupational Therapy
- Feeding Therapy
- ABA
- Parent Behavior Consultation
- Not Sure

Client's Name
First Last

Client's Birth Date*
MM slash DD slash YYYY

Client's Gender
- Male
- Female
- Other

Phone*

Preferred Method of Contact*
- Phone Call
- Email
- Text Message
TherapyWorks has permission to contact me via my preferred method.

Location*
City State ZIP Code

Are you looking for In-Person Therapy or Teletherapy Services?*
- In-Person Therapy
- Teletherapy

Description

Schedule

This field is hidden when viewing the form
TherapyWorks is in-network with BlueCrossBlueShield PPO, Aetna and United Healthcare plans and can bill those plans directly. If you have out-of-network insurance, we can submit claims to most other plans but require payment after each session, and we will direct any insurance reimbursement to you.
- I have a BlueCrossBlueShield PPO, Aetna or United Healthcare plan and would like you to bill my plan directly for services.
- I have out-of-network insurance so will pay for services after each session but would like you to submit claims on my behalf.
- I will not be using insurance and will pay out-of-pocket for services.
Select Your Insurance*
TherapyWorks can bill in-network insurance plans directly. If you have an out-of-network plan, we can submit claims on your behalf but require payment after each session, and we will direct any insurance reimbursement to you.
- Blue Cross Blue Shield
- Aetna
- United Healthcare
- Cigna
- Humana
- Tricare
- Medicaid
- Private pay/Paying out of pocket
- Other
Do you have secondary insurance?*
- Yes
- No
If you don't have your insurance information handy, please email a copy of your card to [email protected] at your earliest convenience.

How did you hear about us?
- Friend/Family or Word of Mouth
- Pediatrician
- Hospital Referral List
- Therapist
- Internet Search
- CITY of Support
- Other
Please specify

We are committed to protecting your personal information and your right to privacy. Please read our privacy policy for more information on how we handle your data and use it to respond to your request.*
- I accept the Privacy Policy.
Comments
This field is for validation purposes and should be left unchanged.

Get Started

To get started, please fill out the form below.

"*" indicates required fields

To start our placement process, please complete this short form.

Who are you seeking services for?*

A Child

An Adult

I am looking for ...*

Speech Therapy

Physical Therapy

Occupational Therapy

Feeding Therapy

ABA

Parent Behavior Consultation

Not Sure

Client's Name

First Last

Client's Birth Date*

MM slash DD slash YYYY

Client's Gender*

Male

Female

Other

Your Name*

First Last

Email*

Phone*

Location*

City State ZIP Code

Preferred Method of Contact*

Phone Call

Email

Text Message

(TherapyWorks has permission to contact me via my selected method)

Are you looking for in-person or teletherapy services?*

In-Person Therapy

Teletherapy

Describe the reason you are seeking therapy.

What days and times work best for therapy?

This field is hidden when viewing the form

TherapyWorks is in-network with BlueCrossBlueShield PPO, Aetna and United Healthcare and can bill those plans directly. If you have out-of-network insurance, we can submit claims to most other plans but require payment after each session, and we will direct any insurance reimbursement to you.

I have a BlueCrossBlueShield PPO, Aetna or United Healthcare plan and would like you to bill my plan directly for services.

I have out-of-network insurance so will pay for services after each session but would like you to submit claims on my behalf.

I will not be using insurance and will pay out-of-pocket for services.

Select Your Insurance

TherapyWorks can bill in-network insurance plans directly. If you have an out-of-network plan, we can submit claims on your behalf but require payment after each session, and we will direct any insurance reimbursement to you.

Blue Cross Blue Shield

Aetna

United Health Care

Cigna

Humana

Tricare

Medicaid

Private pay/Paying out of pocket

Other

Do you have secondary insurance?*

Yes

No

If you don't have your insurance information handy, please email a copy of your card to [email protected] at your earliest convenience.

How did you hear about us?

Friend/Family or Word of Mouth

Internet Search

Pediatrician

Hospital Referral List

Therapist

CITY of Support

Other

Please specify

We are committed to protecting your personal information and your right to privacy. Please read our privacy policy for more information on how we handle your data and use it to respond to your request.*

I accept the Privacy Policy.

Comments

This field is for validation purposes and should be left unchanged.

"*" indicates required fields

To start our placement process, please complete this short form.

Who are you seeking services for?*

A Child

An Adult

I am looking for …*

Speech Therapy

Physical Therapy

Occupational Therapy

Feeding Therapy

ABA

Parent Behavior Consultation

Not Sure

Client's Name

First Last

Client's Birth Date*

MM slash DD slash YYYY

Client's Gender*

Male

Female

Other

Your Name*

First Last

Email*

Phone*

Location*

City State ZIP Code

Preferred Method of Contact*

Phone Call

Email

Text Message

(TherapyWorks has permission to contact me via my selected method)

Are you looking for in-person or teletherapy services?*

In-Person Therapy

Teletherapy

Describe the reason you are seeking therapy.

What days and times work best for therapy?

This field is hidden when viewing the form

TherapyWorks is in-network with BlueCrossBlueShield PPO, Aetna and United Healthcare and can bill those plans directly. If you have out-of-network insurance, we can submit claims to most other plans but require payment after each session, and we will direct any insurance reimbursement to you.

I have a BlueCrossBlueShield PPO, Aetna or United Healthcare plan and would like you to bill my plan directly for services.

I have out-of-network insurance so will pay for services after each session but would like you to submit claims on my behalf.

I will not be using insurance and will pay out-of-pocket for services.

Select Your Insurance

TherapyWorks can bill in-network insurance plans directly. If you have an out-of-network plan, we can submit claims on your behalf but require payment after each session, and we will direct any insurance reimbursement to you.

Blue Cross Blue Shield

Aetna

United Health Care

Cigna

Humana

Tricare

Medicaid

Private pay/Paying out of pocket

Other

Do you have secondary insurance?*

Yes

No

If you don’t have your insurance information handy, please email a copy of your card to [email protected] at your earliest convenience.

How did you hear about us?

Friend/Family or Word of Mouth

Internet Search

Pediatrician

Hospital Referral List

Therapist

CITY of Support

Other

Please specify

We are committed to protecting your personal information and your right to privacy. Please read our privacy policy for more information on how we handle your data and use it to respond to your request.*

I accept the Privacy Policy.

Name

This field is for validation purposes and should be left unchanged.