PATIENT INTAKE FORM

Please fill out the following form to help us determine your next steps.

Child's Full Name

Child's Date of Birth

Child's Health Insurance: Please include 2ndary if applicable

Insurance Id Number:

Parent/Guardian's Name

Phone

Street Address

City and State

Parent's Email Address

Does your child have Any Medical Conditions that they are being treated for by a physician (i.e. epilepsy)? Yes or No

Does the child need Speech and/or Occupational Therapy?

No

Yes

Does your child attend Daycare/Preschool or Elemenatry School?

Yes

No

Preschool or Elementary School Name. Please include the times your child attends

Does the child have an ASD diagnosis? If so, do you have the ASD report?

No

Yes, and I have the ASD report.

Yes, but I do not have the ASD report.

Do you require Translation Services?

No

Yes

Do you have Religious Preference?

No

Yes

I declare that the info I’ve provided is accurate & complete

We will be in contact SOON!

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