Skip to content
Provider Form
(401) 600-1683
Book Appointment
Home
About Us
Our Services
Physical Therapy At Home
Occupational Therapy At Home
Neurological Rehabilitation
Functional Fitness Training
Amputee Rehabilitation
Post-Surgical Rehabilitation
Fall Prevention and Balance Training
Specialized Programs
PowerUP to Parkinson’s
Wheelchair and Mobility Device Evaluations
Caregiver & Family Support
Walk Club and Community Exercise Classes (Planned Expansion)
Concierge Membership Program
Educational Seminars and Workshops
Telehealth Services
Studio Locations
Physical Therapy & Wellness in Groton, CT
News & Events
Contact Us
Blog
Home
About Us
Our Services
Physical Therapy At Home
Occupational Therapy At Home
Neurological Rehabilitation
Functional Fitness Training
Amputee Rehabilitation
Post-Surgical Rehabilitation
Fall Prevention and Balance Training
Specialized Programs
PowerUP to Parkinson’s
Wheelchair and Mobility Device Evaluations
Caregiver & Family Support
Walk Club and Community Exercise Classes (Planned Expansion)
Concierge Membership Program
Educational Seminars and Workshops
Telehealth Services
Studio Locations
Physical Therapy & Wellness in Groton, CT
News & Events
Contact Us
Blog
2023 Christmas Gift List
,
Adaptive Equipment
,
Occupational Therapy
Portable Vehicle Support Handle
December 11, 2023
Clytie
Join Our Newsletter
Sign up our newsletter to get update information, news and free insight.
SIGN UP
Latest news
Technology plus a fighting spirit equals a perfect fit
07 Mar 2025
Healthy At Home…Mobile Services That Come to You
07 Mar 2025
Dr. Shayla Adams PT, DPT: Inspiring People to Live Better
07 Mar 2025
Dr. Adams invited to be part of Elder Care Panel Discussion
07 Mar 2025
SO Rhode Island Leading Lady 2022!
27 Feb 2025
View on Amazon
Facebook
Twitter
Reddit
WhatsApp
NEW PATIENT FORM
Referring Provider’s Name
Provider’s Credentials
Practice Name
Provider’s Email Address
Provider’s Phone Number
Provider’s Fax Number
Office Address
Patient’s Full Name
Patient Date of Birth
Patient Phone Number
Patient Email Address
Home Address
Insurance Provider (if applicable)
Reason for Referral
Diagnosis (if applicable)
Services Required
Physical Therapy
Occupational Therapy
Functional Fitness/Wellness
Parkinson’s Program
Other
If Other Please Specify
Preferred Location for Services
In-Home
Studio/Clinic
Telehealth
Select Option
Is the Patient Currently Receiving Home Health Services?
Yes
No
HIPAA Compliance Disclaimer & Consent Checkbox (e.g., "I confirm that I have obtained patient consent to share their information with INSPIRE Physical Therapy & Wellness.")
SUBMIT
SCHEDULE APPOINTMENT
Appointment Type
Choose An Option
In-Home
In-Office
Type Of Therapy
Choose An Option
Physical Therapy
Occupational Therapy
Speech Therapy
Acupuncture
First Name
Last Name
Phone
Email
Preferred Date
Preferred Schedule
Morning
Afternoon
Evening
Choose An Option
Choose Your Location (Connecticut)
Choose An Option
Old Saybrook
Essex
Old Lyme
East Lyme
Waterford
New London
Salem, Montville
Uncasville
Ledyard
Preston
Lisbon
Plainfield
Sterling
Canterbury
Griswold
Voluntown
North Stonington
Mystic
Groton
Stonington
Choose Your Location (Rhode Island)
Choose An Option
Westerly
Hopkinton
Richmond
Charlestown
South Kingstown
Narragansett
Exeter
North Kingstown
East Greenwich
West Warwick
Warwick
Cranston
Providence
Johnston
East Providence
How Did You Hear About Us?
Choose An Option
Internet Search
Friend Or Family Recommendation
Doctor Recommendation
Doctor Referral List
Advertisement
Promotional Code
Are you a returning patient?
Yes
No
send
NEW PATIENT FORM
Client's Full Name
Client Date Of Birth
Email Address
Client's Phone Number
Client's Home Address (Street, City/Town, State)
Diagnosis or Reason for seeking Therapy
Primary Insurance (Plan and Member ID)
Secondary or Supplemental Insurance (Plan and Member ID)
Primary Care Physician (Name)
Best Person to Contact for Scheduling
Are you currently seeing a Home Health Physical Therapist, Occupational Therapist or Nurse?
Yes
No
I'm not sure
If you are a Physical Therapist, Occupational Therapist, Nurse or Physician, please provide us with your name, agency or hospital, best contact number + email, and likely Discharge Date below so we can follow up with you as needed about this referral
I agree to receive email communication regarding appointment updates and marketing communication from INSPIRE Physical Therapy and Wellness
If you choose 'I Agree' above, which email address would you like to use:
SUBMIT