Refer a Child for Therapy

ViaThera connects families with independent OT, PT, and SLP providers for in-home, community-based, and telehealth therapy in Colorado.

1. Your information

Practice / organization

Phone

Email (for status updates)

Save my information for future referrals

2. Patient information

First name *

Last name *

DOB *

Parent name

Parent phone

Parent email

3. Referral details

Disciplines *

OT PT SLP

Reason for referral

Clinical findings / concerns

Diagnosis codes (optional)

Routine Urgent

This child has an active IFSP (early intervention)

Additional notes

4. Insurance

Payment type

5. Referral letter or prescription (optional)

I am the ordering provider for the services indicated above and authorize evaluation and/or treatment of this patient. This submission serves as my electronic signature.