Getting Started 1 Services Requested Occupational Therapy Evaluation Therapy Services Physical Therapy Speech Therapy Evaluation Therapy Services Physical Therapy Patient Information 2 Patient (Child) Information First Name Middle Initial Last Name Gender Male Female Date of Birth Siblings? Yes No If yes, how many siblings? 1 2 3 4 5 Who does this child live with? Relationship to child? Name of School or Daycare 3 Patient's Medical Information Pediatrician Name Pediatrician Phone Pediatrician Address (if known) Has your child received any diagnosis? If so, please specify Any secondary diagnosis? If so, please specify Diagnosing Physician Diagnosing Physician's phone Please list any other medical conditions 4 Emergency Contact Name Relationship Phone Name Relationship Phone 5 Mother/Guardian 1 Mother/Guardian 1 Occupation Address City State Zip Home Phone Cell Phone Email Address 6 Father/Guardian 2 Father/Guardian 2 Occupation Address City State Zip Home Phone Cell Phone Email Address Insurance/Payment Information 7 Primary Insurance Information Is this patient covered by insurance? Yes No Primary Insurance Company Telephone Address Group # ID or Policy # Effective Date Termination Date Primary Member Name Relationship to Patient Primary Member DOB Primary Member SSN Employer 8 Secondary Insurance Information Is this patient covered by insurance? Yes No Secondary Insurance Company Telephone Address Group # ID or Policy # Effective Date Termination Date Primary Member Name Relationship to Patient Primary Member DOB Primary Member SSN Employer Patient Behavior Questionaire 9 What are your goals for your child? 10 What activities do your child enjoy? How often does s/he do these activities? 11 What hobbies does your child have? 12 Does your child exhibit any of the following? (check all that apply) Impulsivity Resistant to change Difficulty controlling anger Mood swings Dislikes certain textures Little or no sense of safety Hyperactivity Obsessive/Compulsive behaviors Non-compliance Difficulty with change in routine Anxiety Difficulty Transitioning Aggression Spins body or objects Clumsy Easily distracted Lack of focus in school Seems to "space out" at times Withdrawn Poor frustration tolerance 13 Please list any community resources that your family is currently utilizing Documentation If you have any of the documents listed below, please attach them prior to submitting your intake form. 14 Front and back of insurance card(s), if available. 15 Prior evaluation(s), if applicable. 16 Doctor referral or prescription for therapy services, if applicable.
