School Therapy Services Request Form

Please indicate your anticipated OTA The Koomar Center’s Occupational Therapy and/or Speech Therapy requested needs for the school year below.
 
 
Name of Person Completing Form:
 
 
 
 

Services Requested

Please check the below box(es) you would like OTA The Koomar Center to provide at your school.
Consultation/Observation to teachers and staff regarding analysis of tasks, environmental modifications to assist in addressing children’s sensory processing needs, attention, motor skills, self-help skills, feeding skills, and play.
On-Site Screenings, following a consultation/observation.
Training/education of staff and/or families.
On-Site Direct Services, 1:1 and/or small group model.
 
Please check below Specialty Requested
Occupational Therapy Services
Speech and Language Services
Both
 
Service Model
Weekly
Monthly
One time In-Service or Consultation (School Workshop/Education Day)
 
Please indicate if you anticipate finances to be a potential barrier to accessing our services:
 

Once received we will set up an introductory call to review our services and work on developing a plan to meet your needs.

A contract will be shared separately, once services are mutually agreed upon, to then be reviewed and signed by both parties.  

Thank you!

Please reach out to Meaghan Sullivan at Msullivan@otathekoomarcenter.com with any additional questions!