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? * Required

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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