Please fill out the information below completely and a staff member from Scottish Rite for Children will contact your patient's family/guardian to schedule an appointment and answer any questions. Referrals for dyslexia/learning disorders should be directed to the Center for Dyslexia Application Process section of the Dyslexia page.

Note: If you are a parent or guardian of a patient, please complete the Patient Online Appointment Request.
*
Question - Required - Preferred Location



 

Referring Provider Information
*  


*  


 

Practice Information
   


   


*  


*  


  Enter Practice Email Address Below

*

 

 
Question - Not Required - Please let us know which email communications you would like to receive:


 

Patient Information
*  


*  


 
Question - Not Required - Date of Birth




 

Parent / Guardian Information
*  


*  


*  


 

Appointment Information
*  


 

   Please leave this field empty