Downloadable Forms

New Patient Intake Forms

(Print and turn in at our clinic)

Please contact our clinic if you'd rather fill out your new patient forms electronically!

Dyslexia Case History Form (pdf)

Speech/Language Case History (pdf)

Patient Registration Form (pdf)

Patient Payment Contract (pdf)

Physician Referral Form

(Print and fax to Clinton Office at 660-383-1650 or Knob Noster Office at 660-687-0221)

physican referral form (pdf)

2023 Summer Therapy Programs

(Fill out the form below. Parents can drop off the form at either location and/or email to office@thepediatricplacellc.com)

2023 summer programs (pdf)

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We are expanding our services and looking for therapists!