Play OnWords Initial Contact Form
Thank you for reaching out to POW! Shortly after completing this form, you will receive a "Welcome" email from our patient portal software: PlayOnWords.Theraplatform.com. Please follow the directions to create a password, log in, and complete our intake form.  Once the intake forms are completed, we will reach out to schedule the initial appointment with the appropriate specialist. Should you have any questions, please do not hesitate to contact us: hello@playonwordsvi.com or 340-727-7529 (text,  WhatsApp, voice).
Sign in to Google to save your progress. Learn more
Email *
Is your child currently seeing other specialists? *
If "yes", please list the specialists they currently see (e.g., OT, Speech, Psych, Developmental Specialist)
Does your child currently carry a diagnosis? *
Required
Patient's Name (First, Last) *
Patient's Birthdate *
MM
/
DD
/
YYYY
Legal Guardian's Name and Relationship to Child: *
Guardian Phone Number:
 *
Guardian Email: *
General Concerns:
Health Insurance
We accept almost all health insurance plans offered in the USVI: Cigna, MAP, MAPFRE, UHC, Aetna International, ELAN, Triple S, UBS. If your company is not listed, please still provide your insurance information. 
Do you have active health insurance? *
If you have health insurance, list the name of the company and membership number:
How did you hear about us? *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Play OnWords Therapeutic Services, LLC.

Does this form look suspicious? Report

Google Forms