Getting Started

1 Services Requested

EvaluationSpeech TherapyOccupational TherapyOrofacial Myofunctional TherapyDyslexia TutoringFeeding TherapyExecutive Function/ADD/HD Training

Patient Information

2 Patient (Child) Information

First Name

Middle Initial

Last Name

Gender

MaleFemale

Date of Birth

Siblings?

YesNo

If yes, how many siblings?

12345

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?

YesNo

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?

YesNo

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)

ImpulsivityResistant to changeDifficulty controlling angerMood swingsDislikes certain texturesLittle or no sense of safetyHyperactivityObsessive/Compulsive behaviorsNon-complianceDifficulty with change in routineAnxietyDifficulty TransitioningAggressionSpins body or objectsClumsyEasily distractedLack of focus in schoolSeems to "space out" at timesWithdrawnPoor 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.