Contact Brighton Center's Pediatric Therapy Clinic

Brighton Center Pediatric Therapy Clinic for Children Ages 3 to 5

Have questions about Brighton Center's Pediatric Therapy Clinic for children ages 3 - 5?
Contact us by completing our convenient online form and someone will be in touch within 48 hours.

If you need to reach us sooner, you may call 210.826.4492.

Child First Name *

Child Last Name *

Parent First Name *

Parent Last Name *

Language Spoken at Home *

Phone *

Email *

School District *

Address *

City *

State *

Postal code *

Household Status *

Family with Grandma/Grandpa responsible for Grandchildren
Other Family
Other Non-Family
Single Parent/Caregiver with Child
Two Parent/Caregiver with Child
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Child Date of Birth *

Child's Gender *

Male

Female

Ethnicity *

American Indian / Alaskan Native

Asian

Black / African American

Hispanic / Latino

White

Other

Does your Child have Medicaid? *

Yes

No

Type of Insurance

Reason for Referral *

Have you received other services from Brighton Center *

Preschool

Pediatric Therapy

None

Early Childhood Intervention

How Did You Hear About Us? *

Agency Info

Name and Number of Person Completing Form *

Agency Name or Relationship to Child *

Is Parent Aware of Referral *

Yes

No

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We would love to know more about these Brighton Services: *

Brighton Preschool

Brighton Early Childhood Intervention for 0-3 Year Olds

Brighton Pediatric Therapy Clinic for 3 - 5 Year Olds

Special Education Support Services

Parent Workshops

None