Referral

from Parent/Other

Thank you for contacting Solace Pediatric Healthcare. Referring your child to us is the first step in receiving the necessary information so you can make the best decision for your child’s plan of care.

To schedule a comprehensive evaluation with one of our licensed pediatric clinicians, please provide below as much information on the secure encrypted form as possible, as it is required to begin the process to determine if ongoing therapy is needed. In addition, please provide your preferred method of communication (phone, email or text) and include the best days/times to schedule an evaluation with your child.

Once your secure encrypted form is submitted, a member of our Patient Access Team will contact you within 48 hours to review your information and match your child with the appropriate clinician in your respective area. In an effort to best meet potential therapy needs, please note preferred days/times that are convenient for therapy. If ongoing therapy is recommended, your clinician will contact you to schedule the treatment sessions and discuss the plan of care with your child.

At Solace Pediatric Healthcare, our licensed therapists are carefully screened and work collaboratively with you to achieve the greatest outcomes in the most successful environment — your home.

If you prefer to contact us via phone to discuss your child’s situation, please contact us or view our list of locations for the phone number nearest you.

Referral Form

*Denotes mandatory field

Referral Parent/Other
Gender
Do You Prefer Text or Call

Home Address
Home Address
City
State/Province
Zip/Postal
Is the address where therapy is requested if different than home - (ie. Daycare, Other's home)
What services are needed?

Primary Insurance

Maximum upload size: 516MB
Checkboxes