Initial Inquiry Form - Cary Location | Emerge Pediatric Therapy

Child's Name*

First

*

Last

Date of Birth*

Age*

Gender*

I am inquiring about the following services:*

If you selected "other," please specific below:

Which Emerge location are you interested in?

How did you hear about us?*

If 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 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.*

Initial Inquiry Form – Cary Location

Fill Out the Initial Inquiry Form

Initial Inquiry Form -Cary Location