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Referral Form

Supported Person's Best Point of Contact

Please include name, phone number, and email

Is there a legal guardian or authorized decision-maker?
Yes
No

If no, type No.

PT Referral Justification (check all that apply)

*Informed Consent and Available Services

At Mindful Movement Therapy and Wellness LLC, we believe every individual and their support network deserves clear, transparent information so they can make confident decisions about their care. Under Virginia’s Developmental Disability (DD) Waivers, individuals have the right to choose their own providers for therapeutic consultation services.

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We offer Physical Therapy (PT) consultation services for individuals of all ages. Our services are indirect and focused on empowering caregivers—including parents, guardians, and support professionals—to carry out the strategies outlined in the Individual Support Plan (ISP). This may include assessment, caregiver training, environmental recommendations, and ongoing consultation designed to support the person’s unique needs and goals.

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We are committed to working collaboratively and respectfully with your full team, and we support your right to select the providers and services that align best with your goals.

Let’s Work Together

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