Pediatric Occupational Therapy Appointment Request

Please review and complete this form to request an appointment.

    Thank you for your interest in Intuition Wellness Center. Here is some information that may be helpful:

    • Pediatric occupational therapy is available for children ages birth to 12.
    • Services are typically billable to Blue Cross Blue Shield insurances.
    • Self pay fees for services are available to view on our Fee Schedule.
    • Team members at Intuition Wellness Center have limited availability. Prospective clients with flexibility of scheduling are the most successful in matching to services.
    • If you are seeking information on our Wellness Programs, you are not required to complete the following questionnaire.
    • The questionnaire below is required in order to determine Intuition Wellness Center’s ability to meet your needs for clinical services. To request services, please call 520-333-3320 or complete the following prospective client questionnaire:












      MaleFemaleOther










      BCBSAetnaPsychology TodayInternet (eg., Google)PCPOther ProfessionalOther



      Fine Motor SkillsSelf CareMuscle ToneInfant DevelopmentAttention/RegulationCoordinationSensory ProcessingCognitive DevelopmentVisual Motor SkillsVisual Perceptual Skills





      YesNo



      YesNo



      YesNo



      YesNoNA, prospective client is an adult



      YesNoNA, prospective client is an adult



      Please supply supporting court documents at intake or scan and email them to contact@intuitionwellness.com prior to your intake appointment.



      MedicalBehavioral HealthOtherNone


      If you have previous behavioral health or medical treatment history, please bring a copy of records (e.g., treatment summary, treatment plan, testing reports, etc) at the initial intake appointment. You can also email PDF documents to contact@intuitionwellness.com.



      BCBSSelf-Pay


      If you choose Insurance payment, please provide the following information for insurance verification (Please note that doctoral students counseling services are not billable to insurance):




      Thank you for taking the time to complete the questionnaire. Please click “Request an Appointment” to submit to the Intuition Wellness Center team for review and processing. It typically takes 3-7 days for the team to review requests and formulate a response. Intuition Wellness Center receives many requests each week. If caseloads are full, you will be given other referrals.