Radiant Moments Pediatric Therapy

Parent/Guardian’s Information:

Parent/Guardian First & Last Name

Phone Number

Email

Child’s Information:

Child First & Last Name

Date of Birth

Address

Where would you like us to see your child for therapy (select all that apply)?

Home

School (non-public)

Our office at My Little Farmer in Durham (Monday & Friday afternoon slots available)

If you selected "Home" please provide the address:

If you selected "School" please provide the address:

If we are not able to see your child at their home or school, would you be willing to meet us at our office at My Little Farmer in Durham (Monday & Friday afternoon slots available)?

Yes

No

What is your child’s schedule availability for therapy (days/times)?

What are your goals for your child?

Does your child have any medical diagnoses in their medical record (e.g., autism, cerebral palsy, Down syndrome, genetic condition, chronic otitis media, tongue tie, cleft lip/palate, etc.)? This helps us bill insurance appropriately.

How did you hear about us?

Pediatrician Information:

Pediatrician First & Last Name

Office:

Phone Number:

Payment Information

If you plan to use your insurance benefits, please provide the following:

Member ID:

Subscriber (Policy Holder) First & Last Name:

Subscriber (Policy Holder) Date of Birth:

Contact

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