Physician Referrals

A trusted referral partner in supporting every child’s communication journey

How to Refer a Patient

At The Child Inspired, we’re passionate about helping children reach their full communication potential through play-based, family-centered therapy. We value our partnerships with pediatricians and medical professionals who share our mission of early intervention and whole-child support

If you have a patient who may benefit from speech therapy, please complete the referral form below or fax your office’s referral form to 980-216-8436. Our team will take care of the rest — from contacting the family to coordinating care and keeping your office updated along the way.

What Happens Next

Family Contacted: Within 1–2 business days
Evaluation Completed: Full assessment and findings shared with family
Therapy Begins: In-office, preschool, or home sessions
Ongoing Collaboration: Updates to your office (with parent consent)

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Client Information

Name*

Date of Birth*

Parent/Caregiver Name*

Phone Number*

Address*

Email Address*

Insurance Name*

Insurance ID*

Physician Information

Practice Name*

Physician Nane*

NPI*

Phone Number*

Fax*

Areas of Concern

Areas of Concern*

Speech/Articulation

Receptive–Expressive Language Disorder

Fluency

More Information