Myofunctional Therapy Referral Form

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Please complete the following form to refer a patient to Goleta MyoWorks for myofunctional therapy.

Patient Information:

Patient Name *

Age

Parent/Guardian (if minor)

Phone Number *

Email *

Reason for Referral (check all that apply):

Tongue Thrust

Mouth Breathing

Orofacial Myofunctional Disorder (OMD)

Tongue Tie / Lip Tie (Pre- or Post-release therapy)

Improper Swallow Pattern

Thumb/Finger Sucking

Speech Concerns

Sleep-Disordered Breathing / Snoring

TMJ / Bruxism / Orofacial Pain

Orthodontic Support (Pre- or Post-treatment)

Other

Additional Notes

Referring Provider Information:

Provider Name *

Submit

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