First Steps Pediatric Therapy Specialists

1231 Greenway Dr. #100 • Irving, Texas • 972-871-1800

First Steps Pediatric Therapy Specialist
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There are two ways you can refer your child or patient. Option 1 simply complete the information below and submit your referral directly to First Steps Pediatric Therapy Specialists, or Option 2 click on the download PDF referral form, print the form fill out the requested information and fax to 972-871-1802 or Toll Free 888-725-6483. Once either option is completed, someone will contact you within 24 hours.

Click here to Download First Steps PDF Referral Form
Download the Texas Authorization Form


First Name *

Last Name *

Date of Birth *

Parent Name *

Home Street Address *

City *

State *

Zip Code *

Time of Day *

Primary Phone *

Alternate Phone

Primary Language *
Translator Needed

Insured Name *

Medicaid/ Policy # *

Service(s) Requested *

Physical Therapy

Occupational Therapy

Speech Therapy

Name of person making referral*

Referries Phone Number*

Physician Name *

Physician Phone # *