Abilities Pediatric Therapy Interest Form
Thank you for your interest in Abilities Pediatric Therapy! 

Please complete the form below to provide details of about your child and your availability. After completing, our referrals team will confirm therapist availability based on the location and availability you provide. 

If a therapist is available, you will receive an email join Ensora to set up your Parent Portal and enter payment details. The assigned therapist will also contact you directly to schedule the initial evaluation visit.
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Child's Full Name (Legal)
Date of Birth
MM
/
DD
/
YYYY
Sex
Parent/Guardian Name (Primary Contact)
Relationship to Child
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Primary Contact Phone Number
Primary Contact Email Address
Home Address
What specific type(s) of therapy are you seeking?
Current concerns or reasons for seeking therapy services for your child?
Please provide your availability (preferred days/time blocks)
Does your child have any formal diagnoses or relevant medical history (i.e. premature birth)?
I acknowledge that Abilities Pediatric Therapy current rates are as follows:
Initial evaluations - $305 
Follow up sessions - $155
 *
Required
I acknowledge that this request is contingent on therapist availability based on the location and availability I provided above: *
Required
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