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

PATIENT INFORMATION

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

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#