DeLoach Therapy Services

Patient Intake Forms

Thank you for your interest in DeLoach Therapy Services, our pediatric occupational and physical therapy clinic.

Attached is our patient intake forms. Please fill these out and return them, along with a copy of your insurance card, to us as soon as you can. They may be dropped off to our clinic, scanned and emailed to or scanned and faxed to 337-284-3040.

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In addition to the completed intake forms and copy of your current insurance card, we also need a signed script/referral from your pediatrician. This can be obtained by calling your pediatrician and requesting that they fax it to us at 337-284-3040. As soon as we receive all of these documents, we will give you a call to schedule an evaluation.

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Please call our office in the event that you need to reschedule. All patients are responsible for a $50.00 no-show fee. Please see our billing policy located within our intake forms for more details.

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If you have any questions, please do not hesitate to call our office at 337-534-8978.