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Physical Therapy Application

"*" indicates required fields

Date

Name*

First Last

Gender*

Date of Birth*

Age*

Address*

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

County*

Phone*

Email*

Name of person completing this form:*

Relationship to applicant:*

Who referred the applicant to RRC?*

Please describe concerns that prompted this referral and provide examples:*

List any family history of medical/learning deficits:*

Does the applicant have a medical diagnosis? (i.e., Autism, Down Syndrome, Learning Disability, Dyslexia, Stroke/Aphasia, Parkinson’s, etc.)*

Yes

If yes, Please describe & provide date of diagnosis

Has the applicant been a client at RRC in the past?*

Yes

If yes, when and what services were recieved

Is the applicant currently receiving physical therapy at another facility?*

Yes

If yes, please provide the name and location

Has the applicant received physical therapy at another facility in the past?*

Yes

If yes, please provide the name and location

Father/Guardian:

Phone

Mother/Guardian:

Phone

Physical Therapy Doctor's Order

Max. file size: 32 MB.

**If you do not have this you can get your doctor to fax this to us at 662.842.0941

Agreement*

I understand this form should be completed in its entirety. All information will be held confidential and not released to anyone without patient/parent/guardian written permission. This application will be submitted in the order that it is received. Further information may need to be obtained before the applicant is scheduled for evaluation. Once applicant is scheduled for evaluation, 24-hour cancellation notice is required for rescheduling.

Please Check Box above agreeing you understand

Comments

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Physical Therapy Application

If you have any questions or concerns about our application please call us at 662.842.1891

Explore

Services

615 Pegram Dr Tupelo, MS 38801 662-842-1891

Jamie Martin

Dyslexia therapist

Nita Crowell

Dyslexia Specialist

Robby Parman

Executive Director

Wanda K. Gray

Special Instructor

Peggy Lindsey

Physical Therapy Tech

Gretchen Brown, OTR/L, CKTP

Occupational Therapist

Bre Ashe

Developmental Director

Penny Grosse, Med, CALT

Dyslexia Therapist

Anna Claire Bowers, M.S., CCC-SLP

Speech Therapist

Tricia Pate

Office Manager

Penny Barber

Administrative Assistant

Tina Finch, M.S., CCC-SLP

Dyslexia Specialist

Kay Mathews, M.S., CCC-SLP

Speech Therapist

Bethany Reed, M.S., CCC-SLP

Speech Therapist

Parker Stephenson

Dyslexia therapist

Allyson Malone

Dyslexia therapist

Kari Robison, LPTA, CKTP

Physical Therapist Assistant

Hannah Smith Long

Aquatic Therapy Tech

Kammi Riddle, M.S., CCC-SL

Speech Therapist

Laurie Alford

Dyslexia Therapist

Paige Roye

Dyslexia Tester

NiCole Carter

Dyslexia Therapist

Natalie Allen, COTA/L

Occupational Therapy assistant

Kendall Walker

Jeff Finch

Administration

Twila Goolsby

Dyslexia therapist

Brandy Evans, RPT, CKTP

Physical Therapist