Referral Form

DV Therapy provides both speech and occupational therapy services in and around the areas of Antelope Valley, Bakersfield, Los Angeles, and San Gabriel Valley.

You can book either a Speech and Language Evaluation or Occupational Therapy Evaluation, by filling out our form here.

Once all information has been gathered, our team will reach out to you directly with further information.

Clinical location

Child's Name (required)

Date of Birth (required)

Full Address (required)

Parent's Name (required)

Cell Phone

Email (required)

Doctor's Name

Preferred Method of Communication? (required)

Is this evaluation for speech or occupational therapy? (required)

Do you have an active referral for Speech and/or Occupational Therapy? (required)

Have you had a Speech & Language or Occcupational Therapy evaluation within the past 6 months? (required)

Insurance Carrier

Insurance ID#

Zip Code

Requested Setting

Medical Diagnosis (Please list any related diagnosis)

Reason for Speech Therapy Screening Request (if applicable):
Misarticulating Sounds/SpeechLanguage ComprehensionMisarticulating Sounds/SpeechListening SkillsVoices Differences (such as hoarseness, hypernasality, pitch, rate, volume)Grammar DifficultiesExpressive LanguageGrammar DifficultiesDifficulty with Fluency

Comments (Please Provide Specific Examples to Support Request)
* The More Information The Better *

Availability

*ANY CHANGES TO THE ABOVE INFORMATION NEEDS TO BE COMMUNICATED TO OUR BILLINGDEPARTMENT. FAILURE TO DO SO MAY RESULT IN A GAP IN SERVICE. THE FAMILY IS FINANCIALLY RESPONSIBLE FOR ALL SERVICES NOT COVERED BY INSURANCE*

A Super-Bill can be provided upon request for insurance reimbursement. Will this be necessary?

How did you hear about DV Therapy?

Insurance Card Upload - front and back

Check out our Reviews!

					<img src="https://www.dvtherapy.com/wp-content/plugins/wp-review-slider-pro/public/partials/imgs/yelp_stars_5.png" alt="5 star rating" class="wprevpro_t1_star_img_file">A few of my daughters received therapy with Iddo. His professionalism, adaptation to kids, ability to be innovative and help... read moreA few of my daughters received therapy with Iddo. His professionalism, adaptation to kids, ability to be innovative and help them grow is something I have never experienced before. They were excited to see him when he stopped by and have learned a lot and no longer need speech therapy! Thank you Iddo! I highly recommend him to anyone with kids that is  looking for a therapist that really cares about every child. read less				
<img src="https://www.dvtherapy.com/wp-content/plugins/wp-review-slider-pro/public/partials/imgs/yelp_outline.png" alt="Yelp Logo" class="wprevpro_t1_site_logo">
<img src="https://s3-media0.fl.yelpcdn.com/assets/srv0/yelp_styleguide/514f6997a318/assets/img/default_avatars/user_60_square.png" alt="Josh M. Avatar" class="wprevpro_t1_IMG_4 wprevpro_avatarimg" />Josh M.
3 years ago

					<img src="https://www.dvtherapy.com/wp-content/plugins/wp-review-slider-pro/public/partials/imgs/yelp_stars_5.png" alt="5 star rating" class="wprevpro_t1_star_img_file">DV Speech therapy has been life changing for my family and our 3 yr old son.  He adores Miss... read moreDV Speech therapy has been life changing for my family and our 3 yr old son.  He adores Miss Mariah. She is so sweet and patient with him it helps him open up and he's vey willing to learn and listen to her.  At 2 years old he was barely saying 5 words and this lead to frustration for all of us.  But now he makes us laugh so much he doesn't stop talking.  We can see his personality and talk thru behavior issues. He is more confident and open to learn.   It makes a huge difference for all of us as a family.  We are very grateful. read less				
<img src="https://www.dvtherapy.com/wp-content/plugins/wp-review-slider-pro/public/partials/imgs/yelp_outline.png" alt="Yelp Logo" class="wprevpro_t1_site_logo">
<img src="https://s3-media0.fl.yelpcdn.com/assets/srv0/yelp_styleguide/514f6997a318/assets/img/default_avatars/user_60_square.png" alt="Joy G. Avatar" class="wprevpro_t1_IMG_4 wprevpro_avatarimg" />Joy G.
2 years ago

					Being a part of the DV Therapy Being a part of the DV Therapy is extremely rewarding. Every day we have the pleasure of helping children communicate.... read moreBeing a part of the DV Therapy is extremely rewarding. Every day we have the pleasure of helping children communicate. There is nothing more rewarding than helping someone find their voice, especially when you get to do it while having fun. Every day I leave DV Therapy with a smile on my face, knowing that I've made a little bit of a difference in someone's life. read less				
<img src="https://www.dvtherapy.com/wp-content/plugins/wp-review-slider-pro/admin/partials/fb_profile.jpg" alt="Meghan E. Avatar" class="wprevpro_t1_IMG_4 wprevpro_avatarimg" />Meghan E.
10 months ago