Registration Form for Adult Services

Your Legal Name*

First

Last

Preferred Name (if applicable):

Your Date of Birth*

Your Age*

Your Gender/Preferred Pronoun*

Parent/Guardian Name (if applicable)

First

Last

Parent/Guardian Contact

Your Email*

Your Phone Number*

Primary Member ID (for our office to verify benefits)

Secondary Insurance

Secondary Member ID

Main Area of Concern:*

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

Are you interested in Telehealth services?*

Yes

Maybe

Would like more information

Availability:

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

Questions?

Word Verification

Adult OT Services – Sensory Connections