TCS Intake Form

Next Steps

Please have you/your child's PCP fax a script for your desired therapy(s) to 717-370-6315. Please contact us with any questions!

Please complete this form in order to be added to our wait-list for services. We will reach out to you as soon as we have availability in order to schedule you for an evaluation.

Client Information:

Patient First Name

Patient Last Name

Date of Birth

Sex

Preferred Pronouns

Service(s) seeking: Select all that apply. Services subject to availability.

Occupational Therapy

Speech Therapy

Feeding Therapy (specialized OT)

Parent/Guardian Name(s)

Patient's Primary Address:

City

State

ZIP

Primary email address

Primary Phone

Additional Phone

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relationship to Patient

I would like to opt in to receiving: Reminders will be sent to primary information indicated above.

Email appointment reminders

What is your availability for appointments? Check all times you would be able to regularly attend treatment appointments.

Weekday mornings

7:30 am - 12:00 pm

Weekday afternoons

12:00 pm - 3:30 pm

Weekday after school

3:30 pm - 6:00 pm (Please note wait times are much longer for these appointment times due to high demand)

If you have additional comments regarding your availabiliy, describe here:

Please check here if you would like to be placed on our STANDBY LIST to be called in the event of last minute cancellations. This will typically be for same-day or next-day evaluation appointments.

This may decrease your wait time for evaluation.

Insurance and Billing Information:

Name of person responsible for bills (copays, deductibles, unpaid balances):

Address:

Write "same" if same as primary address above

City

State

ZIP

Phone

If "other," please list here:

Please note that we only participate with the insurances listed above in the dropdown menu.

ID #

Group #

Policyholder's Name

If "other," please list here:

Please note that we only participate with the insurances listed above in the dropdown menu.

ID #

Group #

Policyholder's Name

Is the patient a child?

Yes No

Family Information:

Is this child in foster care?

Yes

Was this child adopted?

Yes

Please list all people living with this child in your home, as well as their ages.

Primary language spoken at home:

Preschool/School Information

Does your child currently receive Early Intervention Services?

Yes: 0-3

Yes: IU

No, but did in the past

No, never received EI

Support/Service Coordinator Name and Phone:

Which service(s) and at what frequency?

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

Does your child attend school?

Yes

Name of school:

School District

Current Grade Level

If your child receives school-based supports, please select which one(s) below. Please bring a copy of your child's most recent IEP to your appointment if you are comfortable doing so.

Life Skills

Occupational Therapy

Speech Therapy

Physical Therapy

Autistic Support

Hearing Support

Emotional Support

Vision Support

Learning Support

Medical Information

Diagnosis/diagnoses:

Write N/A if patient does not have a diagnosis

Are you seeking services to assist with symptoms of hypermobility and/or dysautonomia?

Yes No

Which of these conditions have you/your child been diagnosed with or suspect that you are experiencing?

Hypermobility Spectrum Disorder

Hypermobile Ehlers-Danlos Syndrome

Postural Orthostatic Tachycardia Syndrome

Mast Cell Activation Syndrome

Gastroparesis

Sjogrens Syndrome

Cranio-cervical instability

Autism

ADHD

If you/your child has other conditions/complications not listed above, please list here.

What are your/your child's most challenging symptoms on the average day?

Mark the areas on the image where you/your child experience pain on the average day.

If you have found anything that helps your/your child's pain, please describe here.

Please list 2-3 daily activities that are important to you/your child, that are currently negatively impacted by hypermobility symptoms.

These are activities you would like therapy to target.

Primary Care Provider Name:

Primary Care Practice Name

Primary Care Practice Phone Number

In addition to primary care, what specialists or medical providers do you/your child regularly see?

Please select all services that you/your child is currently or already receiving on an OUTPATIENT (Not school or EI) basis.

Physical therapy

Occupational therapy

Speech therapy

Feeding therapy

ABA

Mental health

None

Please list any past surgeries and/or hospitalizations. Include approximate dates.

History of seizures?

Yes

If yes, please explain:

History of allergies?

Yes

If yes, please explain:

Has hearing been tested?

Yes

If so, results:

Pass

No Pass

Do you/your child currently use orthotics/equipment of any type?

Yes

If yes, please explain:

Please list any current medications:

Client Profile

What are some of your child's favorite toys or activities?

What are some of your favorite hobbies or activities?

What are some of your child's least favorite toys or activities?

Are you currently experiencing more stress than usual?

What approaches or services have you already tried to help you with your symptoms?

How does your child show or communicate that they are upset or distressed?

How does your child show or communicate that they are happy or excited?

What are your goals for therapy?

What questions or concerns would you like your therapist to be sure to address at your evaluation appointment?

Your information will be encrypted.

TCS Intake Form

Next Steps

Please complete this form in order to be added to our wait-list for services. We will reach out to you as soon as we have availability in order to schedule you for an evaluation.

Next Steps

Therapy and Counseling Services