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    • Our People
    • Testimonials
  • Services
    • Speech Therapy
    • Occupational Therapy
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  • Insights
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    • New Patient Forms

Logo Image

  • About Us
    • Our People
    • Testimonials
  • Services
    • Speech Therapy
    • Occupational Therapy
    • Behavior Therapy
    • Physical Therapy
    • Educational Programs
    • Social Emotional Learning
    • Teletherapy
  • Insights
    • Blog
    • FAQ
  • Contact
    • New Patient Forms

New Patient Forms

ABA Intake Form Expand

CHILD INTAKE FORM ABA

Child Intake Form for Behavior Therapy/ABA
  • Child's Information

  • Date Format: MM slash DD slash YYYY
  • Type of ServiceDates/AgesName of Provider 
    To list multiple services/providers, click the plus tab on the right to create another row.
  • Family Information

  • NameAgeRelation to the child 
    To add additional family members, click the plus tab to the right.
  • TypeName 
    To add more than one pet, click the plus tab to the right.
  • Parent Information

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Relation to ChildRelated Condition/ Diagnosis? 
    To add more than one, click plus tab to the right.
  • Child's Health History

  • MedicationDosesFrequencySide Effects 
    To add more than one medication, click the plus tab to the right.
  • Child's Educational Information

  • If yes, please provide us with a copy of the most recent IEP and ETR.
  • Child's Strengths and Favorites

  • Date Format: MM slash DD slash YYYY

Child Emergency Contact Information Expand

CHILD CARE EMERGENCY CONTACT INFORMATION

  • Date Format: MM slash DD slash YYYY
  • Emergency Contacts

    Person to contact when attempts to reach parents are not successful and who may pick up the child.
  • Persons Authorized to Pick Up the Child

    We must have written permission for anyone other than parent/ guardian to pick child up from the center.
  • Child's Medical Emergency Contact

  • Child's Health Insurance

  • Parent/Legal Guardian Consent and Agreement for Emergencies


  • Date Format: MM slash DD slash YYYY

  • Date Format: MM slash DD slash YYYY

Policies and Consent to Therapy Services Expand

Therapy & Wellness Connection Policies & Consent to Therapy Services

    Check all that apply.
  • Date Format: MM slash DD slash YYYY
  • Client Communication

Photo Release Expand

Photo Release for Social Media, Marketing & Media

  • Date Format: MM slash DD slash YYYY

Insurance Intake Form Expand

Insurance Intake Form

  • Insurance Information

  • Date Format: MM slash DD slash YYYY
  • Insurance Information Release

  • Assignment of Insurance Benefits:

  • Date Format: MM slash DD slash YYYY

Therapy & Wellness Connection Policies & Procedures Expand

Therapy & Wellness Connection Policies

Let's Connect

(330) 748-4807

10245 Brecksville Road. Brecksville, OH 44141

Services

  • Speech Therapy
  • Occupational Therapy
  • Behavior Therapy
  • Physical Therapy
  • Social Emotional Learning
  • Educational Programs

About Us

Therapy and Wellness Connection is a leading, innovative provider of Cleveland speech therapy, occupational therapy, physical therapy, behavior therapy, individualized education and supplemental support services for children and young adults with a broad range of delays, disorders and disabilities.

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