Apply for Services at Quest

Welcome to our application form - we look forward to talking with you about your child and the services that we provide. Please complete the application for services below.  Once the application is complete and submitted, Quest will contact you for further information to begin the process. 

On the application, please note the earliest time of the day that you are available for therapy appointments.  Quest can accommodate children up to 120 lbs. If your child is unable to sit upright without support, the weight limit is 60 lbs. There is often a waiting list for both physical and occupational therapy; therefore, you may want to send in the form months before your child is ready to get started.

Patient's Name *
Patient's Name
Gender *
Date of Birth *
Date of Birth
Relation *
Address *
Address
Ethnicity
The following information is used in summary for data collection purposes ONLY, and will remain confidential.
Family Size
The following information is used in summary for data collection purposes ONLY, and will remain confidential.
Approximate Household Gross Income
The following information is used in summary for data collection purposes ONLY, and will remain confidential.
Insurance Information
Phone
Phone
Phone
Phone
HOURS OF OPERATION
Please select your availability on Mondays:
There may be a waiting list, but please select the times your child is available, and our office will contact you.
Please select your availability on Tuesdays:
There may be a waiting list, but please select the times your child is available, and our office will contact you.
Please select your availability on Wednesdays:
There may be a waiting list, but please select the times your child is available, and our office will contact you.
Please select your availability on Thursdays:
There may be a waiting list, but please select the times your child is available, and our office will contact you.
Please select your availability on Fridays:
There may be a waiting list, but please select the times your child is available, and our office will contact you.
The Saturday waitlist is currently full. If you choose Saturday as your only therapy day the wait for services could be one year or more.
Services Interested In:
MEDICAL INFORMATION
Date of Onset
Date of Onset
Phone
Phone
Is child receiving therapy elsewhere?