Serving families in the 
Lehigh Valley from our
Coopersburg and 
Emmaus offices since 2014
(484) 863-9220

Valley Family Therapeutics, LLC

Outpatient Pediatric Clinic offering PT, OT, and SLP services

Patient Forms

All forms can be downloaded, completed, and sent to Valley Family Therapeutics through:

Fax: (484) 353-5157

Email: [email protected]

Please fill out the following forms and bring with you to the first treatment session:

Permission to Treat Form 

Patient Intake Form

Financial Agreement and Insurance

HIPAA Release Form

Additional Forms

If you are unsure of which forms you need, please contact our Office Manager, Dr. Lisa Seed at (484)-863-9220.

Autism Screening - Child and Family Intake

Prescription for Services

Insurance Pre-authorization Form

Please provide a copy (you can email a photo of it from your phone) 

of the front and back of your insurance card as well.  Thank you!

Feeding Therapy Intake