New Patient Forms

Please complete the intake form for the service(s) you are interested in pursuing for your child!

In addition, please send the additional documentation needed to our fax (504) 565-7329

or email to info@tlcnola.com. We will reach out to you to schedule your child's evaluation once all

documentation is received. Thank you!

Speech Therapy

Please complete the intake form below and send a referral and hearing screening from your child's pediatrician.

NEW CLIENT - SPEECH THERAPY FORM

Occupational Therapy

Please complete the intake form below and send a referral from your child's pediatrician.

NEW CLIENT - OCCUPATIONAL THERAPY FORM

Feeding Therapy

Please complete the intake form below and send a referral from your child's pediatrician.

NEW CLIENT - FEEDING THERAPY FORM

Physical Therapy

Please complete the intake form below and send a referral from your child's pediatrician.

NEW CLIENT - PHYSICAL THERAPY FORM

Credit Card Authorization Form

All clients are required to complete a credit card authorization form to be used if payments are not received by the deadline. Please complete and return this form to the office.

CREDIT CARD AUTHORIZATION FORM

We’d love to hear from you.

We’d love to hear from you.

Please fill out the form below or call us if you have any questions.

CONTACT US