This form is encrypted and secure to protect your privacy. All information entered is for the personal use of TheraChoice only. Simply fill out the form below with as much detail as possible and we will respond to you within a day.

You may also call us at 727-452-1710.

Your Name: (required)

Your Email: (required)
( Double check your email is correct ) We will coordinate by email first and then by phone.

Phone Number:

Therapy Service your are seeking:

Therapy for: (select one from drop down menu)

Current age of therapy recipient:

Enter Date of Birth of therapy recipient: (Month/Day/Year)

Name of City therapy recipient resides in:

Name of School they are attending (if any):

Had recent Evaluation? YesNo

(if Yes) Name of Clinic that did Evaluation:

Your insurance provider: (enter private for private pay)

Add any additional information about the individual therapy will be provided for, though this field is optional, any other important details and needs TheraChoice is aware of from the onset will greatly reduce the preliminary setup time.

Wait for the confirmation page after you click "Send".