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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 Therapist
- Physical Therapist
- Occupational Therapist
- Feeding Therapist
- ABA (Multi-Disciplinary Approach)
- 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-Home Therapy or Teletherapy?*
- In-Home Therapy
- Teletherapy

Description

Schedule

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*
- Blue Cross Blue Shield
- Aetna
- United Healthcare
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
- Roots Autism Solutions
- 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.

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 Therapist
- Physical Therapist
- Occupational Therapist
- Feeding Therapist
- ABA (Multi-Disciplinary Approach)
- 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
Location*
City State ZIP Code
Email*
Phone*
Preferred Method of Contact*
- Phone Call
- Email
- Text Message
TherapyWorks has permission to contact me via my selected method
Are you looking for In-Home Therapy or Teletherapy?*
- In-Home Therapy
- Teletherapy
Description
Schedule
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*
- Blue Cross Blue Shield
- Aetna
- United Health Care
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
- Roots Autism Solutions
- 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.
Phone
This field is for validation purposes and should be left unchanged.