Initial Inquiry Form – Cary Location Fill Out the Initial Inquiry Form Initial Inquiry Form -Cary Location Completing this form will alert our staff that you would like to speak with a therapist. One of our office staff will be in contact to set up a time to speak with a therapist on the phone. Completing this form will help our therapists prepare for their phone call with you. Child's Name* First * Last Date of Birth* Date Format: MM slash DD slash YYYY Age*Gender*MaleFemaleI am inquiring about the following services:* Occupational Therapy Speech Therapy Physical Therapy Feeding Therapy Group Therapy Reading Tutoring Infant Therapeutic Services Infant Massage CDIT Parent Coaching Telehealth Speech Therapy Telehealth Occupational Therapy Telehealth Feeding Therapy Telehealth Reading Tutoring Telehealth Services: Other Orofacial Myofuntional Therapy If you selected "other," please specific below:Which Emerge location are you interested in?Durham (3905 University Drive)Cary (3110 NC-55)No preferenceHow did you hear about us?*Select from belowDoctor ReferralFamily/Friend/Word of MouthDevelopmental ChecklistFacebookInstagramFlyers in the communityEvent sponsorCommunity Event (e.g. Bulls Game, Resource Fair, etc.)Ad at WRAL online advertisementEmerge event (e.g. Parent workshop)Podcast advertisementInternet searchPreston Life MagazineIf you would like to share the name of the person or other entity that referred you to Emerge, please fill out below:Type of Insurance:*Emerge Pediatric Therapy is an in-network provider for all Tricare insurance plans, Health Choice, and NC Medicaid. We reserve a limited number of slots for children under these programs. We will bill these plans directly and collect any co-payments and deductibles as necessary. We are out-of-network for private commercial insurance plans. Please visit our FAQ page on our website to learn more: https://www.emergepediatrictherapy.com/about-us/faq/Caregiver Name (First, Last)*Email* Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country If your child needs treatment, when could s/he come (time of day/day(s) of week)??*What are your concerns for your child (at home, school, etc.)?*What have professionals told you about your child?*Is your child currently receiving any additional services or has s/he received them in the past? If so, please explain.*
