Initial Intake Form

Child's Name *
Child's Name
Child's Date of Birth *
Child's Date of Birth
Parent's Name *
Parent's Name
Address *
Address
Phone *
Phone
Therapy Needs (OT, PT, Speech)
Is your child currently on an IEP? *
An Individualized Educational Plan (IEP) is a plan or program developed to ensure that a child who has a disability identified under the law and is attending an elementary or secondary educational institution receives specialized instruction and related services
Has your child had an evaluation done within the last year? *
(OT, PT, Speech, etc):
Where were they evaluated?
Pediatrician’s Name
Pediatrician’s Name
Pediatrician’s Phone Number
Pediatrician’s Phone Number
Insurance Carrier Phone Number
Insurance Carrier Phone Number
Subscriber's Name
Subscriber's Name
Subscriber's Phone Number
Subscriber's Phone Number
Preference for contacting you to confirm appointments: *