Make a Payment

Please fill out the form below in order to make a payment. Use the notes section if you have questions or concerns!

Name(Required)

First Last

Phone(Required)

Email(Required)

Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

Payment Amount(Required)

Invoice #

Notes

Mailing List Consent

I would like to receive periodic emails and updates from Basal Therapies.

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Supported Credit Cards: American Express, Discover, MasterCard, Visa

Card Number

Expiration Date Month Year

Security Code Cardholder Name

Get in touch!

If you think your child could benefit from our support and services, send us a message!

First Name*

Last Name*

Email Address*

Phone Number*

Concerns
Following directions and answering questionsCommunicating (using gestures, words, etc.)Speaking clearly and being understoodMoving around safely/gross motor skillsPlaying with toysUsing their hands/fine motor skillsSensory concernsEmotional regulationHandwritingMental HealthFeedingOther (Explain below)

Your Message

Mailing List Consent
I would like to receive periodic emails and updates from Basal Therapies.

We accept the following insurances:

8411 Broadband Drive
Suite C & D
Frederick, MD 21701

[email protected]

443-776-0271

301-663-8322

About Us
Services
Preschool
Groups
Resources
Gallery
Careers
Contact Us