Child Intake Form

Request Consultation

Day and Time

Booking Amount:

Price: $50.00

No payment items has been selected yet

Date

First Name

Last Name

How did you hear about us?

Patient's Name

Patient's DOB

Gender

Was the patient adopted?

Yes

No

If applicable, tell us more about the adoption.

Does that patient have any siblings?

Does the patient have any medical diagnoses or significant medical history.

School Attended

Educational Diagnosis

Classroom type

Grade

Parent's First Name

Parent's Last Name

Phone/Mobile

Email

Address

Street Address

Street Address Line 2

City

State/Province

Zip Code

INSURANCE INFORMATION

We are in-network with BCBS PPO and Macomb County Community Mental Health. We are also a certified non-network provider for Tricare.

As a curtesy, we will submit billing to out-of-network PPO plans but payment is due at the time of service.

We cannot bill to HMO plans or Medicaid plans. Please contact the office for cash prices.

Primary Insurance

Insurance Provider

Subscriber Name

Subscriber DOB

Policy Number

Group Number

Phone Number

Secondary Insurance

Insurance Provider

Upload a photo of the Front and Back of your insurance card.

Choose File

Physician's Information

Physician's Name

Office or Clinic Name

Phone Number

Do you have a prescription for occupational therapy?

Upload your prescription here.

Choose File

Please describe what your current concerns for you child are at this time.

How can we be most helpful to you and your child?

Do you have any concerns with self-care (bathing, eating, dressing, grooming)?

Do you have any concerns with coordination ( gross and fine motor)?

Is you child flexible with change? Please describe.

How long can your child sit at a table and pay attention to a non-preferred task.

Less than 1 minute

1 to 5 minutes

5 to 15 minutes

15 to 30 minutes

30 minutes or more

Please describe your child's relationships and play with others.

What does your child like to play or do in their free time?

My child can consistently follow multi-step verbal directions.

unable to follow verbal directions

1 step at a time

2 steps at a time

more than 2 steps at a time

Are there any precautions we should be aware of?

Do you have anything thing else to add?

Please complete this form to the best of your ability so we can determine the proper evalautions to administer. We will be in contact within one business day to schedule an evaluation.

Request Consultation

Primary Insurance

Secondary Insurance

Physician's Information

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