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.

Download PDF Referral Form
Download Texas Auth. Form


    First Name

    Last Name

    Date of Birth

    Parent Name

    Home Street Address



    Zip Code

    Time of Day

    Primary Phone

    Alternate Phone

    Primary Language

    EnglishSpanishTranslator Needed

    Insured Name

    Medicaid/ Policy #

    Service(s) Requested

    Physical TherapyOccupational TherapySpeech Therapy

    Name of person making referral

    Referries Phone Number

    Physician Name

    Physician Phone#