Request Evaluation

This form is for parents/guardians to complete. Medical staff can fax referrals to 979-848-8337.

Fill out the form below, and we’ll get back to you promptly.

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Name

First

Last

Child's Date of Birth

Child's Age

Child's Pediatrician

Parent Name

Parent Phone

Parent Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

Please Select a Program

Child's Birth Layout

Type of Therapy Requested

Occupational Therapy
Physical Therapy
Speech Therapy

Comment or Message

Join Us in Making a Difference

At BACH, we are dedicated to fostering an environment where children with developmental challenges can thrive. By providing essential services and unwavering support, we empower families and enrich the lives of our children.

If you would like more information or need to make a referral, please visit our website or contact us directly. Together, we can make a significant impact on the lives of children in our community.