Admin Panel | Intake ST OT PT BH

Public Intake ST OT PT

Welcome to the Sunshine Center Pediatric Therapy Automated Client Intake System. Please fill out the form below and a member of our team will contact you to schedule your first appointment. if you have any questions throughout this process, feel free to contact 918-615-6492, Ext 2.

Services Needed

Speech Therapy

Occupational Therapy

Physical Therapy

Counseling ( currently unable to accept new clients )

What is your child needing help with?

Child's Primary Care Physician

Child's First Name

Child's Last Name

Child's Date of Birth

Gender

Male

Female

Child's Address Info:

Child's Address

City

State

Zip Code

Primary Guardian Info:

Primary Parent/Guardian

Relationship to Child

Parent/Guardian Cell Phone

Primary Insurance Info:

Primary Insurance

Primary Insurance Member Name

Date of Birth

Member #

Group #

Customer Service Phone #

Secondary Insurance Info:

Secondary Insurance

Primary Insurance Member Name

Date of Birth

Member #

Group #

Customer Service Phone #