Patient Intake Form

Primary Insurance Provider*

Policy Holder Name and DOB*

Primary Member ID*

Group ID or Group Name*

SSN

Insurance Provider Phone

Send Claims To:

Street Address City State / Province / Region Postal / Zip Code Country

Secondary Insurance Provider

Secondary Policy Holder Name and DOB

Secondary Member ID

Secondary Group ID or Group Name

Secondary Insurance Provider Phone

Send Secondary Claims To:

Street Address City State / Province / Region Postal / Zip Code Country

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School Information >

What is the reason for seeking occupational therapy evaluation or services? *

What are your child’s strengths? What does your child enjoy doing? *

What is your primary concern for your child at this time? What tasks are difficult for your child to perform?*

What would you like to be easier for your child and/or your family? *

Do you have concerns regarding school? Does your child’s teacher(s) have any concerns? If yes, please specify.

Describe your child’s preferred activities and/or toys. What does your child do with preferred toys?*

Does your child enjoy playing with peers or siblings, prefer solitary play, or prefer adult interaction?*

What would you like to learn from our evaluation? *

What is your preferred learning style/How do you learn best? (i.e. visual learner, auditory learner, etc.) *

Please provide us with any other information that you feel is important for us to know about your child:*

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Attachments

After downloading and completing the Parent Checklists PDF, please attach it below.

Please attach any prior reports that your child has related to past rehabilitative services, school services, medical diagnoses, etc.

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Patient Intake Form – Child