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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)

    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.

    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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