New Client Intake

For questions please email:

heidi@therapysfc.com

Client Information

First name of child:

Last name of child:

Child's Preferred Name

Date of birth

Please Confirm Date of birth

Diagnosis (if any):

Does your child know about their diagnosis?

Yes

Partially

Gender:

Date of onset:

Preferred Pronoun:

What is your child's primary mode of communication (verbal, ASL, AAC)

Name of School:

School, daycare or preschool

Grade Level:

Type of Classroom or School:

For example, general education, type of special education, ect.

Parent or Guardian Information

Please select:

Mother

Father

Legal Guardian

First name:

Last name:

Email address:

Occupation/Employer:

Home address:

City:

State:

Zip Code:

Cell phone number:

Home phone number:

Other Parent or Guardian Information - This section is required when the child lives with both parents, or if parents share custody.

If not applicable, please indicate N/A:

Please select:

Mother

Father

Legal Guardian

Not applicable

First name:

Last name:

Email address:

Occupation/Employer:

Home address:

City:

State:

Zip Code:

Cell phone number:

Home phone number:

Address child resides at if different from above:

If the same, please write "same."

Who does your child live with (e.g. parents, guardians, siblings)?

Names/Ages of siblings:

Was your child adopted? If so, at what age?

Primary language spoken at home:

Is a second language spoken at home or daycare/school?

Name of the person who referred you to Therapy Services for Children.

Physician Information

Child's Primary Care Physician (PCP):

PCP address:

PCP phone number:

Referring physician:

Complete if different than PCP.

Client Health Information:

Current medications (if any):

Any known food/medication allergies/restrictions:

Does your child carry an EpiPen?

Yes

Does your child wear glasses or corrective lenses?

Yes

Child's hand dominance:

Right

Left

Unknown or not established

Prenatal and birth history

Length of pregnancy (weeks):

Check all that apply:

Excessive illness during pregnancy

Prenatal Exposure to alcohol/drugs

Labor complications

Breech presentation

Cesarean section

Additional prenatal/birth information:

Has your child ever had a surgery or been hospitalized

YES

If you answered "YES" above please provide DATE, SURGERY and HOSPITAL:

Has your child seen any of the following specialists?

Ear/Nose/Throat specialist

Neurologist

Psychologist

Orthopedic Surgeon

Vision Therapist

Psychiatrist

None of the above

If you selected a specialist above, please provide us with the name(s) of the provider:

Has your child received an occupational therapy assessment/evaluation or occupational therapy treatment?

YES

If you selected "yes" above, WITH WHOM did they receive an OT assessment/evaluation or treatment?

If you selected "yes" above, WHEN did they receive an OT assessment/evaluation or treatment?

Has your child received a speech therapy assessment/evaluation or treatment?

YES

If you selected "yes" above, WITH WHOM did they receive a speech assessment/evaluation or treatment?

If you selected "yes" above, WHEN did they receive a speech assessment/evaluation or treatment?

Has your child received a physical therapy (PT) assessment/evaluation or treatment?

YES

If you selected "yes" above, WITH WHOM did they receive a PT assessment/evaluation or treatment?

If you selected "yes" above, WHEN did they receive a PT assessment/evaluation or treatment?

Has your child had any feeding issues/do you have any feeding concerns?

YES

If you selected "yes" above, please describe the issues or concern.

Date & results of last hearing test:

Date & results of last vision test:

Significant Family History:

Mobility History

At what age did your child crawl?

Was there anything unusual about your child’s crawl?

At what age did your child walk?

Additional Information

What are your reasons (concerns) for seeking occupational therapy services for your child? What would you like your child to improve, change, or accomplish?

What are your child's strengths?

What does your child like to play with? What does your child do for fun?

Does your child receive any special education services (has an I.E.P.), or have 504 Accommodations?

Please indicate your child’s CURRENT obligations and activities outside of school hours.

Has your child participated in any team sports? Please indicate the sport, how long ago it was, and your child’s response.

Does your child have any sleep difficulties (i.e. difficulty falling or staying asleep; elaborate bedtime routine; needs an adult to fall asleep; too light or too heavy a sleeper, etc.)?

Does your child have any difficulties/differences related to elimination (toileting)?

Does your child have friends that they get together with outside of school (i.e. does your child get invited to play at another child’s house; get invited to birthday parties)?

Does your family have any pets? Is your child fearful of cats or dogs?

Does your child have any other significant fears/phobias?

Any other concerns or eccentricities that your therapist should know in order to understand and help your child?

Does your child have challenges with emotion-regulation/self-regulation?

If you answered "yes" to the question above, what sorts of things make your child upset or cause a melt-down?

Are there any strategies your child (or you) currently use to help with emotion/self-regulation?

Has your child received any “therapy” services (e.g. behavioral, play therapy)? If so, please include name of provider and time frame of treatment.

Has your child experienced trauma (e.g. serious illness of self or caregiver, extended separation from parents, injury, or abuse?)

Please indicate your child’s school schedule, including days of the week attended, and starting and ending time.

Does your family have any beliefs, values, or cultural norms that your therapist should know about in working with your child?

Insurance Information:

IF YOU HAVE HEALTH INSURANCE FROM ONE OF THE FOLLOWING COMPANIES, FOR WHICH WE ARE CONTRACTED, IN-NETWORK PROVIDERS, PLEASE PROVIDE YOUR INSURANCE INFORMATION BELOW, SO THAT WE MAY BILL THEM: BC/BS, CIGNA, FIRST CHOICE, KAISER PERMANENTE PPO (First Choice Health Network), LIFEWISE, PREMERA, REGENCE, and UNIFORM MEDICAL PLAN.

If you have other insurance and would like to submit the claims yourself, please let us know and we will provide you with claims to submit. PLEASE NOTE: OTHER THAN PROVIDING YOU A CLAIM TO SUBMIT, WE DO NO OTHER INSURANCE CONTACT OR FOLLOW-UP FOR ANY INSURANCE COMPANY FOR WHICH WE ARE NOT CONTRACTED, IN-NETWORK PROVIDERS.

Insurance Company:

Customer Service Phone Number:

Subscriber’s Name:

Subscriber’s Relationship to Child:

Subscriber’s Date of Birth:

Is this policy an individual policy (purchased by you for you, and/or your family)?

YES

Is this policy through an employer?

YES

If you selected "yes" above, please provide the name of the employer:

If not applicable please indicate N/A.

Entire ID# including Alpha Prefix:

Group Name:

Group #:

Your information will be encrypted.