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Physician Referrals

Referral Process

- - - For referrals, please contact our Home Health office at (713) 668-6690.
    - Please provide signed orders for an evaluation for treatment.
    - Our staff will verify Medicaid and/or private insurance benefits.
    - Client’s caregiver/parent will be reached by phone to schedule an admission/intake.
    - After the admission, the evaluating therapist will schedule an initial evaluation with the family.
    - Based on the results of that evaluation, the evaluating therapist will recommend the frequency of services in a Plan of Care to be approved by the PCP.
    - The therapist and office staff will assist the family with scheduling appointments.

Download, print, and fill out the Physician Referral Form or fill out the form on this page.

You may also fax your own referral form to our Home Health office at (713) 668-6563.

Digital Referral Form: Physician Use Only

Kids Developmental Therapy

6109 Maple St., Houston, TX 77074 | Phone: 713-668-6690 | Fax: 713-668-6563

Location Selection for Kids Developmental Clinic

Southwest (8021 Bissonnet, Houston, TX 77074 | Phone: 713-774-5437 | Fax: 713-774-5445)

Pasadena (3801 Vista Suite 200, Pasadena, TX 77504 | Phone: 713-910-5437 | Fax: 713-910-5445)

West (9432 Katy Freeway, Suite 320, Houston, TX 77055 | Phone: 713-558-5437 | Fax: 713-558-5445)

North (5206 Airline Drive, Suite D, Houston, TX 77022 | Phone: 713-691-5437 | Fax: 713-691-5445)

Home Health Therapy Requested(Required)

Yes

No

Evaluation and Treatment Requested(Required)

PT

OT

ST

*Select all that apply. Please note, plan of care and evaluation to follow.

Physician Information

Physician's Name(Required)

Physician's Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Physician's Phone(Required)

Physician's Fax

Patient Information

Patient's Name(Required)

Patient's Date of Birth(Required)

Medicaid/ID#(Required)

Patient's Phone Number(Required)

Diagnosis & Referral Information

Patient's Primary Diagnosis(Required)

Patient's Therapy Related Diagnosis(Required)

Physician's Signature(Required)

Typing your name here serves as an electronic signature.

Today's Date(Required)

MM slash DD slash YYYY

Physician's NPI Number(Required)

Δ

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Kids Developmental Therapy | 6109 Maple St., Houston, TX 77074 | 713-668-6690

Kids Developmental Therapy does not discriminate against any person on the basis of race color religion or national origin disability or age in admission treatment or participation in programs services and activities or in employment.

Kids Developmental Therapy complies with the standards for privacy of patient information required by the Health Insurance Privacy and Accountability Act (HIPAA). For further information about our policies and standards please contact Stacy Grazak DPT at 713-668-6690. Notice of Privacy Practices (PDF)

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