Initial Inquiry – Adult

Initial Inquiry at Sensory KIDS

Thank you for inquiring about Adult OT services at Sensory KIDS. After submitting the form, please review the details about getting started under “Intake Process and Forms”. Our office will send a follow up email to confirm your inquiry and we will add you to the waitlist.

Your Full Name*

First

Last

Parent/Guardian Name (if applicable)

First

Last

Your Date of Birth*

Your Age*

Your Gender*

Your Email*

Your Phone Number*

Insurance Provider*

Member ID (for our office to verify benefits)

Secondary Insurance

Secondary Member ID

Your PCP*

PCP Contact Information

Are you interested in Telehealth services?*

Yes

Maybe

Would like more information

Does you have a current diagnosis? If so, please list. (n/a if not applicable)*

What is your availability for future treatment sessions?*

How Did You Hear About Sensory Kids?*

Google Search

Other Internet Search

Spectrums Magazine

Word of Mouth

Physician/Health Professional

Teacher/School

Other

Name of Referrer (teacher, physician, etc) - "n/a" if not applicable*

Questions?

Word Verification

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Find Us

1425 N Killingsworth St
Portland, OR 97217 | Map

P: 503-575-9402
F: 888-769-4431
info@sensorykidsot.com

Portland Occupational & Sensory Therapy for Children | Sensory Kids Portland | Website Design by SimplyFine Design | Photography by Bill Purcell