Clinic Application

Affiliate Survey

Clinic Name

Number of Practices

Specialty

Lead Physician First Name

Lead Physician Last Name

Lead Physician Email

Website

Primary VT Address

VT Coordinator Full Name

VT Coordinator Email

VT Coordinator Cell Phone

# Of Vision Therapists In Practice

Estimated Percent Of Revenue Comes From Vision THerapy

How Many Children Did You Assess for VT Last Year? (Approximately)

What Percent of the children assessed Began VT Treatment?

Do You Get Referrals From... (Select All That Apply)

Pediatrics Neurology Educators Other

What Percent Of VT Patients Assessed Are From Referral?

What percent come from School Nurses or Other Educators?

Do You Provide Pro Bono Services To Families Who Cannot Afford VT?

Yes No Only Discounts

What is the AVERAGE cost of the VT services you provided last year?

What is the AVERAGE number of sessions per VT Patient last year?

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