TCS Intake Form

Next Steps

Please submit completed forms prior to your evaluation appointment. Please also have your child's PCP fax a script for your desired therapy(s) to 717-370-6315. Please contact us with any questions!

Client Information:

Child First Name

Child Last Name

Child's Date of Birth

Sex

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

Occupational Therapy

Speech Therapy

Caregiver Name(s)

Child's Primary Address:

City

State

ZIP

Primary email address

Primary Phone

Additional Phone

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

Email appointment reminders

Text message appointment reminders

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

Primary Insurance Carrier:

Please bring your card with you to your appointment.

ID #

Group #

Policyholder's Name

Secondary Insurance Carrier

Please bring your card with you to your appointment

ID #

Group #

Policyholder's Name

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 your child does not have a diagnosis

Primary Care Provider Name:

Primary Care Practice Name

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

No need to list specific providers here, just disciplines. For example, "neurologist, developmental pediatrician"

Please select all services that 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 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

Does 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 child's least favorite toys or activities?

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

Next Steps

Therapy and Counseling Services