New Patient Intake Form

Thank you for your interest in our therapy services. To help better serve you, please provide us with the information requested below. Please be assured that the information you provide will be held confidential, and is necessary for our staff to determine and provide appropriate evaluation and therapy services.

Therapy Intake Form

Step 1 of 4

Child's Information

Today's Date:(Required)

Child's Name:(Required)

First Last

Date of Birth:(Required)

Age:(Required)

Grade Level:(Required)

Sex:(Required)

Diagnosis:(Required)

Age of diagnosis:(Required)

Please specify all services you are interested in:(Required)

Speech Therapy

Occupational Therapy

Physical Therapy

Feeding Therapy

Sensory Integration Therapy

Group Sessions

Referring Physician:(Required)

Office Number:(Required)

How did you hear about us?:(Required)

Main Concerns / Reason for Referral:(Required)

Please list 3 goals you would like to see your child achieve in therapy:(Required)

Please list strong motivators for your child (favorite activities, toys, movies, foods, songs, etc.):(Required)

What are your child's biggest strengths?(Required)

What are your child's biggest struggles?(Required)

Authorizations

Authorization Signature:(Required)

Max. file size: 512 MB.

Please upload your digital signature here (i.e. jpg, gif, png,pdf).

Date(Required)

Authorization Signature:(Required)

Max. file size: 512 MB.

Please upload your digital signature here (i.e. jpg, gif, png,pdf).

Date(Required)

Will you be filing with your Insurance Company?(Required)

Yes

Primary Insurance:

Insurance Name:(Required)

Health Plan, if Applicable:(Required)

Member's Name (Policy Holder):(Required)

Member's Date of Birth:(Required)

Member's Relationship to child:(Required)

Member's Employer:(Required)

Member ID#:(Required)

Group Policy#:(Required)

Effective Date:(Required)

Insurance Phone #:(Required)

Secondary Insurance:

Insurance Name:(Required)

Health Plan, if Applicable:(Required)

Member's Name (Policy Holder):(Required)

Member's Date of Birth:(Required)

Member's Relationship to child:(Required)

Member's Employer:(Required)

Member ID#:(Required)

Group Policy#:(Required)

Effective Date:(Required)

Insurance Phone #:(Required)

Release and Exchange of Information

*If you are using insurance to pay for services, we must have contact information and permission to exchange information with your child's primary physician prior to initiating services. Please list all specialists involved in your child's care (All doctors, schools, therapy services etc.)

Profession: Physician/Pediatrician:(Required)

First Last

Phone(Required)

Fax(Required)

Address(Required)

Street Address

Specialist:(Required)

Name(Required)

First Last

Phone(Required)

Fax(Required)

Address(Required)

Street Address

Specialist:(Required)

Name(Required)

First Last

Phone(Required)

Fax(Required)

Address(Required)

Street Address

Name of Child:(Required)

Date of Birth:(Required)

Name of Parent(s) or Guardian:(Required)

Phone:(Required)

If you are separated or divorced, please verify that you are the party above and have legal custody by initialing here:(Required)

Max. file size: 512 MB.

Please upload your digital signature here (i.e. jpg, gif, png,pdf).

Parent/Guardian Authorization Signature:(Required)

Max. file size: 512 MB.

Please upload your digital signature here (i.e. jpg, gif, png,pdf).

Date:(Required)

Authorization Signature:(Required)

Max. file size: 512 MB.

Please upload your digital signature here (i.e. jpg, gif, png,pdf).

Date(Required)

New Patient Intake Form

Therapy Intake Form

Child's Information

Parent Contact Information

Emergency Contact

Please list who lives with the child:

Authorizations

Primary Insurance:

Secondary Insurance:

Release and Exchange of Information

*If you are using insurance to pay for services, we must have contact information and permission to exchange information with your child's primary physician prior to initiating services. Please list all specialists involved in your child's care (All doctors, schools, therapy services etc.)