Refer a Child

About the Referral Process

Thank you for referring a child to Premier Pediatric Therapy! We know you have several options when it comes to pediatric home health agencies, so we are honored to receive your referrals.

All referrals will be processed within 24 hours of receipt, with the goal of having an evaluation completed within 5 business days.

If you have any questions about this process, please don’t hesitate to contact our friendly intake team at (832) 539-1632. We look forward to working with you!

Patient Information
Patient Name:*
Date of Birth:*
Treating Address:*
Street Address Address Line 2 City State ZIP Code
Services Requested:
- Speech Therapy
- Occupational Therapy
- Physical Therapy
- ABA Therapy
Child's Availability:*
- Daytime
- After School
- Any Time
Physician's Name:*
Physician's Phone Number:*
Name of Insurance:*
Type of Insurance*
Medicaid ID
- Policy
- Group
Upload Physician's Referral:
Drop files here or

Max. file size: 2 MB.
Caregiver Information
Name:*
First Last
Phone:*
Email:*
Preferred Contact Method:*
Additional Information:*

Refer a Child

About the Referral Process

Patient Information

Caregiver Information

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Refer a Child

About the Referral Process

Patient Information

Caregiver Information