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About Us
Our Vision
Occupational Therapists
Speech Pathologists
Physical Therapists
Behavioral Therapist/Family Counseling
Services
Our Services
Occupational Therapy
Speech and Language Therapy
Behavioral/Family Therapy
Physical Therapy
Therapeutic Groups
School Based Therapy
Home Health Therapy
Social Skills Groups
New Patients
New Patients
Online Initial Intake Form
Online Developmental Summary Form
COMPLETE REGISTRATION
Resources
Signs and Symptoms
Sensory Integration
Executive Function
Recommended Reading
Sensory and developmental products:
Website Resources
FAQ
Blog
Contact Us
Home
About Us
Our Vision
Occupational Therapists
Speech Pathologists
Physical Therapists
Behavioral Therapist/Family Counseling
Services
Our Services
Occupational Therapy
Speech and Language Therapy
Behavioral/Family Therapy
Physical Therapy
Therapeutic Groups
School Based Therapy
Home Health Therapy
Social Skills Groups
New Patients
New Patients
Online Initial Intake Form
Online Developmental Summary Form
COMPLETE REGISTRATION
Resources
Signs and Symptoms
Sensory Integration
Executive Function
Recommended Reading
Sensory and developmental products:
Website Resources
FAQ
Blog
Contact Us
New Patients
New Patients
Online Initial Intake Form
Online Developmental Summary Form
COMPLETE REGISTRATION
Initial Intake Form
Child's Name
*
Child's Name
First Name
Last Name
Child's Date of Birth
*
Child's Date of Birth
MM
DD
YYYY
Parent's Name
*
Parent's Name
First Name
Last Name
Address
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
*
Subject
*
Phone
*
Phone
(###)
###
####
Child's Grade Level
*
Does your child have any health issues or allergies we should be aware of?
*
Please list any concerns or issues you are seeing at home or school
Therapy Needs (OT, PT, Speech)
Occupational Therapy
Speech and Language Therapy
Physical Therapy
School Based Therapy
Home Health Therapy
Please list any diagnosis your child may currently have
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
Yes
No
Has your child had an evaluation done within the last year?
*
Yes
No
If yes, what evaluation did your child receive?
(OT, PT, Speech, etc):
Where were they evaluated?
School
Outside Facility
Referred by
Pediatrician’s Name
Pediatrician’s Name
First Name
Last Name
Pediatrician’s Phone Number
Pediatrician’s Phone Number
(###)
###
####
Insurance Carrier
Insurance Carrier Phone Number
Insurance Carrier Phone Number
(###)
###
####
Subscriber's Name
Subscriber's Name
First Name
Last Name
Subscriber's Phone Number
Subscriber's Phone Number
(###)
###
####
Subscriber's Date of Birth
Subscriber's Date of Birth
MM
DD
YYYY
ID# with any letter prefix
Insurance Group Number
Preference for contacting you to confirm appointments:
*
Please email to confirm
Please call to confirm
Thank you!