EmailMeForm
Parent Inquiry
At New York Therapy Placement Services, Inc (NYTPS) our primary mission has always been caring for children. If you have any concerns about your child’s development, we are a full service resource -- we are here to help and our dedicated team will guide you.
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Parent
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First
Last
E-mail Address:
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Address
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Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
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Finland
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Germany
Greece
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Iceland
Ireland
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Nauru
New Zealand
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Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
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Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Home Phone Number
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Cell Number
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School District
Child's Full Name
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Child's Date of Birth
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Does your child currently receive services?
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Yes
No
If yes please list the services
Description of Parental Concerns
Please check the service(s) you would like more information on
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Occuational Therapy
Physical Therapy
Speech/Feeding/Stuttering/PROMPT
ABA (Applied Behavioral Analysis)
Mommy and Me Groups
Sensory Motor Groups
Therapeutic Listening
Please check all that apply
Will these services be billed through your insurance?
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Yes
No
If yes, in order for us to better serve you and verify your insurance coverage please provide us the following:
Name of Insurance Plan
Name of Insured
Member ID
Group ID
Phone # on the back of your insurance card
Thank you! Someone from our team will promptly contact you and map out the next steps.