Having the most accurate and reliable information is a key component to helping your child's positive development.

For more details, please visit the following websites:

• www.asha.org

• www.apraxia-kids.org

• www.autismspeaks.org

• Center for Disease Control

• PA Promise for Children

• Everyday I Learn... [PDF]

Complete the following form or call our office at 610-951-4330 to make a referral to our clinic.

* Indicates required fields.

Child's Name: *

Child's Date of Birth: *

Parent Name: *

Parent Phone: *

Parent E-mail: *

Street Address: *

Address (Line 2):

City: *

State: *

Zip Code: *

County:

Services requested:

 Speech Therapy
 Occupational Therapy
 Physical Therapy
 Feeding Therapy
 Social Skills Program
 Teacher Services
 Behavioral Services

Child's Diagnosis:

Primary Insurance:

Secondary Insurance:

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