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About Our Mission Billing Team Insurance Gallery Classes & Camps Feeding Support Group Postnatal Yoga On-Demand Classes Speech/Language & Social Groups SpOT Playgroups CPR Classes Camps Services Speech & Language Feeding & Swallowing Occupational Therapy Tongue Tie Nutrition Orofacial Myology LSVT Loud Baby Steps New England Gender Affirming Voice Modification RI Team Speech Language Pathologists Occupational Therapists Floor Time Clinicians Nutritionists MA Team Speech Language Pathologists Nutritionists Occupational Therapists Product Rec. Feeding Dietitian-Recommended Teethers & Pacifiers Infant Toys Infant Nasal Hygiene Nasal Hygiene Voice & Respiratory Therapy Books We Love Toys We Love Bilateral Coordination Toys Sensory Toys Fine Motor Toys Other Products Resources Testimonials Blog Store

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Request an appointment

Use the form below to tell us about yourself/the patient and to schedule an appointment. We will contact you via email for scheduling. Please allow 1-2 business days for a reply. You may also email or call us with questions.

Patient Name *

First Name

Last Name

Patient DOB *

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Patient’s Diagnosis, if applicable

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Payment *

Private Pay (enter N/A in fields below)

Insurance

Insurance Name *

Insurance Member ID *

Insurance Subscriber's Name

First Name

Last Name

Insurance Subscriber's DOB

YYYY

Secondary Insurance Name

Secondary Insurance Number

Parent Name *

First Name

Last Name

Parent Phone *

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Parent Email *

Our team will be communicating with you primarily via email

Pediatrician/PCP Name *

First Name

Last Name

PCP NPI#

Parents Concerns/Reason for Seeking Services *

Office Location *

Please indicate which office you would like to visit.

Appointment Modality *

Please indicate the appointment modality you prefer.

Please select the service(s) you are seeking: *

Speech/Language

Orofacial Myology

Occupational Therapy

Nutrition

Floortime

Feeding

Voice/Parkinson's Disease

Respiratory Therapy

Tongue Tie

Availability for Appointments *

Please indicate the days and times you are available for evaluations and/or treatment.

Student

My child is a Wheeler/Hamilton student.

Yes

Patient's Primary Language *

Parent/Caregiver's Languages Spoken *

Hello! Thank you for your interest in Small Steps Therapy. We received your form and we are obtaining your insurance information. Once we run your insurance and get a referral from your pediatrician/PCP, we will be in contact to schedule your first appointment. We look forward to connecting and serving your family in the near future!