Name

Please enter your name incase I have more questions.

First Name

Last Name

Does this clinic/therapist accept insurance? *

Yes

No

No, but will provide a super bill

What conditions does the clinic specialize in?

Cerebral palsy

Spinal cord injury

Traumatic brain injury

Other (include other conditions in the message blank below)

Services offered *

Check all services offered

Physical Therapy

Occupational Therapy

Speech Therapy

Feeding Therapy

Whole Body Vibration

Therasuit

Neurosuit

Universal Exercise Unit

Neuromuscular Electrical Stimulation (NMES)

Other (include other therapies in the message blank below)