Children's Center for Therapy - Providing Pediatric Physical, Occupational & Speech Therapy Services

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General Information

Child's Name*

DOB*

Parent's Full Name*

Home address*

City*

Zip*

Primary phone*

Secondary phone*

How did you find out about the Children's Center?*

Physician's Information

Primary care physician
(first and last names)*

Child's Needs

Does your child have a diagnosis?

Services Requested (PT, OT, SLP)

What are the main concerns you have for your child?

Have you received therapy services for this problem in the past? (What type, when, from whom?)

Communications Questions

How did you find out about Children's Center for Therapy?

Is it okay for Children's Center for Therapy to leave messages on your answering machine?

Human:

Please note that you will be asked about your insurance information when Children's Center for Therapy contacts you regarding this intake form.