Intake Form – Foundations Therapy

PATIENT INFORMATION

Service Needed(Required)

Occupational Therapy

Physical Therapy

Speech Therapy

Reading Remediation

Feeding Therapy

Sensory Processing Disorder

Patient's Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Female

Male

Other

Address(Required)

Street Address Address Line 2 City State ZIP Code

INSURANCE INFORMATION

Insurance(Required)

Insurance Telephone #(Required)

Policy Holder(Required)

Policy Holder DOB(Required)

Policy ID #(Required)

Policy Group #(Required)

Prior Authorization Required(Required)

Yes

No

PARENT/GUARDIAN

Name(Required)

First Last

Home Phone

Cell Phone

Work Phone

Employer

Employment Type

Part Time

Full Time

Is it ok to leave a detailed message on answering machine or voice mail?(Required)

Yes

No

Is it ok to speak with any other family member/ friend regarding medical treatment?(Required)

Email(Required)

DIAGNOSIS/CONCERNS

Decribe the Diagnosis and/or Concerns

Does patient have prescription for therapy services?

Yes

No

If yes, what is the date on script?

Has patient had an evaluation for desired therapy service(s)?

Does patient currently receive other therapy service(s)?

If so, what & where?

MEDICAL INFORMATION

Referring Physician

Phone

Pediatrician

Phone

SCHEDULE INFORMATION & REFERRAL

Preferred Days/Times(Required)

No-Go Days/Time

Referred By

PATIENT INFORMATION

INSURANCE INFORMATION

PARENT/GUARDIAN

DIAGNOSIS/CONCERNS

MEDICAL INFORMATION

SCHEDULE INFORMATION & REFERRAL

Services

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