TCS Intake Form

Occupational and/or Speech Therapy Services

Please correct the errors described below.

Client Information:

Insurance and Billing Information:

Write "same" if same as primary address above
Please note we do NOT accept Highmark Wholecare or Health Partners Medicaid plans, and are not able to see children with these plans. We are also not able to see children who have Aetna PEBTF HMO plan, even if there is secondary insurance.
Please note that we only participate with the insurances listed above in the dropdown menu.
Please note we do NOT accept Highmark Wholecare or Health Partners Medicaid plans. We are not able to see children who have these plans.
Please note that we only participate with the insurances listed above in the dropdown menu.

Family Information:

Preschool/School Information

Which therapies and how often, ex. ST 30 mins per week

Medical Information

Write N/A if your child does not have a diagnosis
No need to list specific providers here, just disciplines. For example, "neurologist, developmental pediatrician"

Client Profile

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