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LAIPT Appointment Scheduling Request Form
“ Please fill out the form below to request an appointment with LAIPT. Once we receive your request, our team will contact you to confirm the details. We’re here to make the process easy and convenient for you. ”
Patient information
First Name
*
Last Name
*
Phone Number
*
Date of Birth
*
Gender
*
Email Address
*
Home Address
*
City | State | Zip
*
Insurance
*
Insurance ID
*
Appointment Request
Patient Symptoms
*
Provider
*
Provider
A
Occupational Therapists - Katie Willebrands MSOT, OTR/L
B
Occupational Therapists - Zoe Saunders OTD, OTR/L
C
Occupational Therapists - Zaina Kholaki MSOT, OTR/L
D
Occupational Therapists - Kaila Cummings MSOT, OTR/L
E
Occupational Therapists - Claire Casanova OTD, OTR/L
F
Speech Therapists - Craig Gemmill MA, CCC-SLP
G
Speech Therapists - Sophie Baillargeon MS, CCC-SLP
H
Center-based Program - Jill Lipschultz-Rosenthal, M.A
“One of our team members will give you a call back as soon as we receive your request. If you have any concerns, please feel free to call us at (310) 234-0300 or email us at
[email protected]
.”
Submit
