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Theratime

Special Services for Special Children

  • Speech Therapy
  • Occupational Therapy
  • Physical Therapy
  • Interactive Screener

Getting Started

1 Services Requested



Occupational Therapy


Speech Therapy

Patient Information

2 Patient (Child) Information








































3 Patient's Medical Information
































4 Emergency Contact
























5 Mother/Guardian 1




































6 Father/Guardian 2




































Insurance/Payment Information

7 Primary Insurance Information




















































8 Secondary Insurance Information




















































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Aggression Spins body or objects Clumsy Easily distracted Lack of focus in school Seems to "space out" at times Withdrawn Poor frustration tolerance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.





Navigation

  • Home
  • Services
    • Speech Therapy
    • Occupational Therapy
    • Physical Therapy
    • Interactive Screener
  • Classes
  • Getting started
  • Leave a review
  • What people are saying
  • Meet our team
  • Hiring
  • Contact us

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