New Patient Intake Form

New Patient

Enter NA into any fields that do not apply.

    Child’s Legal Name:

    First

    Middle

    Last

    DOB

    Age

    Gender

    Phone

    Home Address:

    City

    State

    Zip

    Parent/Guardian 1

    DOB

    Cell

    Parent/Guardian 2

    DOB

    Cell

    Insurance Company

    ID CARD NUMBER

    Phone

    Medicaid Plan

    ID CARD NUMBER

    Who has legal custody of the child?

    Who lives in the home of the child?

    Name/Relationship to child/Age (if child):

    Emergency Contact Information:

    List who we may call in case of emergency AND who may
    pick up the child from appointments other than custodial parent or guardian.

    Name

    Phone

    Relationship

    Name

    Phone

    Relationship

    Area of Concerns:

    What is the primary concern for having your child evaluated?

    When did you start having concerns?

    What strategies have you already tried?

    What specific skills would you like your child to achieve in therapy?

    Prenatal/Birth History:

    List any complication during pregnancy:

    Any exposure to drugs or alcohol during pregnancy?

    Was your pregnancy full term?

    If NO, please give gestational age:

    Birth Weight:

    Method of Delivery:

    Forceps or Suction used?

    Was oxygen or respiratory assistance required after birth?

    If YES, please explain:

    Did the child experience any complications with feeding?

    If YES, please explain:

    How was your child fed as an infant (Bottle, Breast Milk) and until what age?

    Please list any concerns regarding your child eating habits:

    History:

    Does your child currently receive therapy services at any other location?

    Where?

    List any medical diagnoses that your child has been given:

    List all your child’s medications:

    Developmental Milestones:

    (List age at time of reaching milestone without help)

    Rolling

    Spoke first word

    Sitting alone

    Puts several words together

    Crawling

    Toilet trained

    Walk alone

    Eats with utensils

    Dresses self

    Finger fed self

    Has your Child:

    Had his/her hearing checked?

    Date

    Results

    Had his/her vision checked?

    Date

    Results

    Had their immunizations?

    Are they up to date?

    Please list any allergies:

    Family history:

    Does anyone in your family have a history of the following:

    Communication difficulties?

    Describe difficulty

    Relationship to child

    Physical difficulties?

    Describe difficulty

    Relationship to child

    Learning disability?

    Describe difficulty

    Relationship to child

    Mental illness?

    Describe difficulty

    Relationship to child

    How may we contact you regarding information about your child?

    Home Phone / Voicemail

    Cell Phone / Voicemail

    Email

    How did you hear about us?

    Parent/Guardian Signature

    Print Name

    Date

    Patient/Guardian Contact Information (please print clearly & legibly):

    Email

    Cell Phone

    Parent/Guardian Name (print)

    Signature

    Date