Child's Name*

Parent or Guardian's Name*

Birth Date * Month JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Gender * Female Male

Phone *

Email

Would you like to be added to our monthly newsletter email list? Yes No

How do you prefer to be contacted for appointment confirmations? Phone Text Email

Street Address *

City *

State *

Zip *

Primary Physician Name *

Primary Physician Practice *

Insurance Company * Employer

Insurance ID# Group #

Policy Holder Birth Date

Referred For * OT PT ST

How did you hear about us?

Concerns (Check all that apply and enter comments)

• Anxiety
• Autism
• ADD/ADHD
• Behavioral
• Coordination
• DSI
• Feeding
• Fine Motor

• Gross Motor
• Torticollis
• Orthopedic Injury
• Articulation
• Fluency(Stuttering)
• Voice
• Expressive/Receptive Language

Currently receiving OT/PT/ST elsewhere? No Yes

Where?

How Often? 1x 2x 3x Per Week Per Month

School Name

Does your child have an IEP? No Yes

Availability for Evaluation

Available Days (Check all that apply)

• Monday
• Tuesday
• Wednesday

• Thursday
• Friday
• Saturday

Available Times (Check all that apply)

• Morning
• Afternoon

• Evening

Specific Times

10+1=

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