New Patient Forms

CHILD INTAKE FORM SPEECH

Child's Information
Child's Name*
First Last
Child's Gender*
- Male
- Female
Child's Date of Birth*
MM slash DD slash YYYY
Child's Current Age*
Child's Address*
Street Address Address Line 2 City State ZIP Code
Name of School*
Grade Level*
Name of Primary Care Physician*
Phone Number of Primary Care Physician*
Describe your main concerns.*
Include when the problem was first noticed, who noticed it, and where the problem occurs.
How does your child react to being misunderstood or unable to communicate?*
- Tries again/revises
- Gets angry/frustrated
- Gives up
- Doesn't notice
- This is not a problem
- Other (please specify in the next question)
If you answered "other" to the previous question, please specify your child's response.
Why are you seeking speech-language services for your child?*
Has your child’s physician noticed these concerns? If yes, what were his/her recommendations?*
List all other services your child is receiving/has received, including speech therapy, occupational therapy, physical therapy, ABA/behavior therapy, counseling, psychiatric treatment, etc., as well as the dates and the providers.*
Type of Service Dates/Age of Child Name of Provider

For each additional service, click the "plus" to the right to create another row. If "none," simply type "none" in the first column/row.
How did you learn about us?*
- Recommended by a friend, family member or acquaintance
- Recommended by a professional
- Google search
- Website
- Social media (Facebook, Instagram, etc.)
- Online ad
- Other
If you answered "other" to the previous question or were recommended by an individual, please specify what/who..
With whom does your child live?*
- Biological parent(s)
- Adoptive parent(s)
- Grandparent(s)
- Legal guardian(s)
- Sibling(s)
- Other
Check all that apply.
If you answered "other" to the previous question, please specify with whom the child lives.
List everyone who lives in the same home with your child.*
Name Age Relation to the Child

For each additional person, click the "plus" to the right to create another row.
Do you have family pets?*

Answer yes or no. If yes, please indicate name & type.
Parent Information
Parent 1 Name*
First Last
Parent 1 Gender*
- Select All
- Male
- Female
Parent 1 Date of Birth*
MM slash DD slash YYYY
Parent 1 Address*
Street Address Address Line 2 City State ZIP Code
Parent 1 Primary Phone Number*
Parent 1 Secondary Phone Number
Parent 1 Email Address*
Enter Email Confirm Email
Parent 1 Preferred Method of Contact*
- Primary Phone Number
- Secondary Phone Number
- Email
Parent 1 Place of Employment*

If not applicable, type N/A.
Parent 1 Position at Place of Employment.*

If not applicable, type N/A.
Parent 2 Name
First Last
Parent 2 Gender
- Select All
- Male
- Female
Parent 2 Date of Birth
MM slash DD slash YYYY
Parent 2 Address
Street Address Address Line 2 City State ZIP Code
Parent 2 Primary Phone
Parent 2 Secondary Phone
Parent 2 Email Address
Enter Email Confirm Email
Preferred Method of Contact
- Primary Phone
- Secondary Phone
- Email
Parent 2 Place of Employment

If not applicable, type N/A.
Parent 2 Position at Employment

(If not applicable, type N/A.)
Are there family circumstances that would be helpful for your child's therapist to know? (Custody arrangements, protection orders, etc.)*
Are there other languages spoken at home? If yes, which language(s), how often & with whom?*
Do any other family members have speech, language or related difficulties/disorders (i.e., autism, ADHD, dyslexia, etc.).*
Relation to child Diagnosis/Diagnoses

For each additional relative with relevant diagnoses, click the "plus" to the right to create another row. If none, enter "None" in the first column/row.
Child's Health Background
Describe pregnancy with the child, including any complications.*
Describe labor/delivery with the child, including any complications.*
Type of birth (check all that apply).*
- Spontaneous (not induced).
- Induced.
- Vaginal.
- C-section.
- I'm not sure.
Birth place (hospital/birth center).*
Birth attendant (physician/midwife)
Gestational age (in weeks)*
Birth weight*
Birth length.
Was your child admitted to the NICU?*
- Yes
- No
If your child was admitted to the NICU, how long was he/she there?
Were there any complications after birth or during the first few weeks?*
- Difficulty breathing
- Jaundice
- Difficulty feeding
- Seizures
- Birth defects
- Birth injury
- Other
- No complications
Check all that apply.
If your child suffered post-birth complications, please explain.
Has your child's hearing been tested?*
- Yes
- No
If your child's hearing has been tested, when & where did the testing take place?
If your child's hearing has been tested, what were the results?
- Passed.
- Did not pass.
- Inconclusive.
Describe any serious illnesses, injuries, or medical procedures your child has experienced.*
If not applicable, type N/A.
List any environmental or food allergies.*
If not applicable, type N/A.
List any medications your child is taking or has taken long-term.*
If not applicable, type N/A.
Describe any other conditions or diagnoses identified by your child’s doctor or other professionals.*
If not applicable, type N/A.
Child's Feeding Development
Child was:
- Select All
- Breastfed.
- Formula fed.
- Bottle fed.
Check all that apply.
Specify how long (from _ months until _ months) child was breastfed, formula fed and/or bottle fed.*
Indicate at which age your child began using each of the following.*
Sippy Cup Open Cup Straw Utensils
If not applicable, type N/A.
Describe any difficulties with sucking, swallowing, chewing, eating different textures, etc.*
If not applicable, type N/A.
List child's favorite foods.*
List any food aversions.*

If not applicable, type N/A.
Child's Speech & Language Development
At what age (in months/years) did your child begin each of the following?*
Babbling (bababa) Jargon (bada bama) First word (age & word) Two-word combo (more milk) Three-word combo Sentences
Give your best estimate for each. If not applicable, type N/A.
At what age (in months/years) did your child begin each of the following?
Reading letters Writing letters Reading words Writing words
Give your best estimate for each. If not applicable, type N/A.
At what age (in months/years) did your child begin each of the following?*
Reading sentences Writing sentences
Give your best estimate for each. If not applicable, type N/A.
Child used a pacifier from _ months to _ months of age.*

If child never used a pacifier, type N/A.
Child sucked thumb/finger from _ months to _ months of age.*

If child never sucked thumb/fingers, type N/A.
Who understands your child's speech, and how much do they understand. Give a percentage value for each.*
Parent(s) Sibling(s) Peer(s) Teacher(s) Extended family Strangers
25% = 1 out of 4 words understood 50% = 2 out of 4 words understood 75% = 3 out of 4 words understood 100% = 4 out of 4 words understood
Has your child's speech/language been evaluated before?*
- Yes
- No
If your child's speech/language has been evaluated, please note the place and summarize the findings.
What are a few specific goals or skills you would like your child to attain in speech therapy?*
Is your child aware of his/her communication difficulties?*
- Yes.
- No.
- I'm not sure.
Do you wish to share information with your child, such as goals or diagnosis?*
Child's Strengths & Favorites
Describe your child’s strongest skills and personality traits. What makes your child unique?*
Child's favorite activities/hobbies?*
Child's favorite toys?*
Child's favorite movies/shows?*
Child's favorite books.*
Additional Forms
Additional Medical File Attachments
Drop files here or

Accepted file types: jpg, pdf, Max. file size: 72 MB.

Therapy & Wellness Connection requires digital OR paper submission the following documents if available: Speech-language evaluations, hearing tests, recent medical physical and/or relevant medical exams (e.g., autism diagnosis, etc.). Please also submit any existing or prior plans of care (indicating therapy goals) from any other provider of speech, occupational, physical or ABA therapy. Files may be submitted here in .jpg or .pdf format.

Parent/Guardian Signature

Consent*

I agree that all the information entered here is true and current to the best of my knowledge.

Name of Person Who Completed This Form.*

First Last

Relationship to the child:*

Date This Form Was Completed:*

ABA Therapy Intake Form

CHILD INTAKE FORM ABA

Child Intake Form for Behavior Therapy/ABA

Child's Information
Child's Name*
Gender*
Child's Current Age*
Date of Birth*
MM slash DD slash YYYY
Name of School
Grade*
Do You Have a Primary Care Physician?*
Primary Care Physician's Name
Primary Care Physician's Phone Number
Primary Care Physician's Address
Street Address Address Line 2 City State ZIP Code
Is your child currently being seen by a behavioral health technician?*
Describe your main concerns. Include when problems were first noticed, who noticed and where problems occur.*
Why are you seeking services for your child?*
Has your child’s physician noticed these concerns? If yes, what recommendations did he/she make?*
How did you learn about us?*
Are you currently utilizing any community resources (e.g. support groups, social groups, social services, school-based services or other social supports)?*
List all other services your child has received, including counseling; psychiatry; physical, speech, occupational or ABA therapy, etc. If none, skip..
Type of Service Dates/Ages Name of Provider

To list multiple services/providers, click the plus tab on the right to create another row.
Family Information
With whom does your child live? (Check all that apply.)*
- Biological parent(s)
- Adoptive parent(s)
- Grandparent(s)
- Legal guardian(s)
- Sibling(s)
- Other
List all family members who live with your child.*
Name Age Relation to the child

To add additional family members, click the plus tab to the right.
Please list family pets in the home. If none, skip.
Type Name

To add more than one pet, click the plus tab to the right.
Parent Information
Parent 1 Name*
First Last
Parent 1 Gender
Parent 1 DOB*
MM slash DD slash YYYY
Parent 1 Address*
Street Address Address Line 2 City State ZIP Code
Parent 1 Phone No. 1*
Parent 1 Phone No. 2
Parent 1 Email Address*
Enter Email Confirm Email
Parent 1 Preferred Method of Contact*
Parent 1 Employer*
Parent 1 Job Title*
Parent 2 Name
First Last
Parent 2 Gender
Parent 2 DOB
MM slash DD slash YYYY
Parent 2 Address
Street Address Address Line 2 City State ZIP Code
Parent 2 Email
Enter Email Confirm Email
Parent 2 Phone No. 1
Parent 2 Phone No. 2
Parent 2 Preferred Method of Contact
Parent 2 Place of Employment
Parent 2 Job Title
Are there family circumstances that would be helpful to share with your child’s therapist such as medical issues or legal issues? (e.g., custody arrangements)*
Are there any other languages spoken in the home? If yes, which language(s) and how often?*
Do any other family members any diagnosis or known medical conditions/ disorders? (e.g., ADHD, autism)
Relation to Child Related Condition/ Diagnosis?

To add more than one, click plus tab to the right.
Child's Health History
Describe your pregnancy, including any complications.*
Describe your labor/delivery, including any complications.*
Type of birth (check all that apply):*
- Spontaneous (not induced)
- Induced
- Vaginal
- C-section
Birth Place (hospital, etc.)*
Birth Attendant Name (physician, midwife, etc.)
Gestational Age (in weeks)*
Birth Length*
Birth Weight*
NICU?*
If your child stayed in the NICU, for how long?
Were there any complications after birth or during the first few weeks? (Check all that apply.)*
- Difficulty breathing
- Difficulty feeding
- Birth defect
- Jaundice
- Seizure
- Other
- None
Has your child's hearing been tested?*
If your child's hearing has been tested, when and where?
If your child's hearing has been tested, what was the determination?
Does your child have an infectious or communicable disease?*
If your child does have an infectious or communicable disease, please describe.
List any environmental or food allergies, please include adverse reactions to allergen.*
List any routine medications your child is currently taking or has taken long term.
Medication Doses Frequency Side Effects

To add more than one medication, click the plus tab to the right.
Describe any other conditions or diagnoses identified by your child’s doctor or other professionals.
Please list any spiritual or cultural variables that may impact treatment that we should be aware of.
Click all that apply.*
- Breastfed
- Formula Fed
- Both
If your child was breastfed, for how long? ( __ Months to __ Months.)
If your child was formula fed, for how long? ( __ Months to __ Months.)
At how many months-old did your child begin using a sippy cup? (If still not in use, skip.)
At how many months-old did your child begin using an open cup? (If still not in use, skip.)
At how many months-old did your child begin using a straw? (If still not in use, skip.)
At how many months-old did your child begin using utensils? (If still not in use, skip.)
Describe any difficulties with sucking, swallowing, chewing, eating different textures, etc.*
FAVORITE FOODS*
FOOD AVERSIONS*
Child's Educational Information
Name of School
Classroom Type
Teacher/Grade
School Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Does your child have an IEP?*
If yes, please provide us with a copy of the most recent IEP and ETR.
Child's Strengths and Favorites
Describe your child’s strongest skills and personality traits. What makes your child unique?*
FAVORITE ACTIVITIES / HOBBIES*
FAVORITE TOYS
FAVORITE MOVIES
FAVORITE BOOKS
Parent Electronic Signature*
First Middle Last
Today's Date*
MM slash DD slash YYYY

OT/PT Child Intake Form

Child Intake Form Occupational/Physical Therapy

Individualized Needs Assessment
For Pediatric Occupational Therapy and/or Physical Therapy
Child's Name*
First Last
Child's Date of Birth
MM slash DD slash YYYY
Name of Person Completing This Form*
First Last
Your relationship to the child:*
Is your child adopted?*
- Yes
- No
- Foster child
- I am a relative/legal guardian
Child's Birth History
Child was born:*
- Full term
- Premature
If the child was born prematurely, how many weeks of gestation were they at birth?
How was the child delivered?*
- Vaginal
- C-section
Was your child in the NICU for any amount of time? If yes, for how long?*
Please describe any medical or other complications during pregnancy, labor & delivery or shortly after birth.*
If not applicable, type N/A.
Developmental History
Please indicate at what age your child did each of the following.*
Rolled over Sat alone Crawled Pulled to stand Stood alone Walked alone
If your child has not yet achieved the listed milestone, type N/A for not applicable.
Please indicate at what age your child did each of the following.*
Babbled Said 1st word Drank from cup Used a spoon Toilet-trained Dressed self
If your child has not yet achieved the listed milestone, type N/A for not applicable.
Explain any current physical limitations your child has.*
Any additional comments on your child's development?*
Medical History
List your child's current diagnosis or diagnoses.*
Has your child had any prior hospitalizations? Answer Yes/No. If yes, please describe.*
Has your child had previous surgeries or are they scheduled for any? Answer Yes/No. If yes, please describe.*
Has your child had a previous psychological evaluation? Answer Yes/No. If yes, please describe.*
Name of current physician.*
Phone number of current physician.*
List any medications your child is currently taking.*
If none, type N/A for not applicable.
List any special equipment your child uses, such as splints, braces, adaptive utensils or other.*
If none, type N/A for not applicable.
Do you have any feeding problems or nutritional concerns? Answer Yes or No. If yes, please describe.*
Please check all that apply to your child.*
- Trach
- C-Line
- G-Tube
- Allergies
- Latex sensitivity
- Seizures
- Hearing aids
- Hearing difficulty
- Wears glasses
- Vision problems
- None of the above
If your child has allergies, please detail what those are.
Any other aspects of your child's health that his/her OT or PT should know about?*
Caregiver Concerns
What are your main concerns with your child?*
What are your child's strengths?*
Indicate which of the following your child has received before & for how long. Type N/A for those that are not applicable.*
Speech therapy Occupational therapy Physical therapy ABA therapy
Educational Information
School/educational program child currently attends.*
Current grade level.*
Check any of the following services that your child receives in school.*
- Speech therapy.
- Occupational therapy.
- Physical therapy.
- Special education/IEP.
- Behavior intervention.
- Other special services.
- None of the above.
Has your child's teacher expressed concern about your child's development in any of the following areas?*
- Motor skills
- Social abilities
- Self-help skills
- Learning abilities
- Other
- None of the above
Check all that apply.
Additional comments on your child's education?*
Social/Emotional Development
Does your child interact well with others?*
- Yes
- No
Does your child have trouble making friends?*
- Yes
- No
Detail your child's fears and coping behaviors.*
Does your child have trouble calming himself/herself when upset?*
- Yes
- No
Any additional thoughts/comments on your child's social/emotional development?*
Behavior
Please check all the following that applies to your child.*
- Cries often
- Frequent temper tantrums
- Anxious
- Troubling following directions
- Trouble following routines
- Clumsy
- Weak muscles
- Picky eater
- Mouths objects
- Dislikes hair brushing
- Dislikes brushing teeth
- Avoids touch from others
- Dislikes playground equipment
- Seems to be always "on-the-go"
- Rocks self
- Sensitive to light
- Sensitive to sound
- Poor attention span
- Other
- None of the above
If you answered "other" to the previous question, please give us more details.
Parent Signature
Consent*
I agree this information is true and accurate to the best of my knowledge.
Date this form was completed:*
MM slash DD slash YYYY
Your phone number.*
Your email address.*

Child Emergency Contact Information

CHILD CARE EMERGENCY CONTACT INFORMATION

Child's Name*
First Last
Child's Date of Birth*
MM slash DD slash YYYY
Child's Address*
Street Address Address Line 2 City State ZIP Code
Parent/Guardian Name*
First Last
Parent Home/Cell Phone Number*
Parent Work Number*
Parent Email Address*
Enter Email Confirm Email
Parent Home Address*
Street Address Address Line 2 City State ZIP Code
Place of Employment*
Work Title
Department
Work Contact Person (who usually knows your whereabouts)
Work Contact's Phone Number
Parent/Guardian Name
First Last
Parent Home/Cell Phone Number*
Parent Work Number
Parent Email Address
Enter Email Confirm Email
Parent Home Address
Street Address Address Line 2 City State ZIP Code
Place of Employment
Work Title
Department
Work Contact Person (who usually knows your whereabouts)
Work Contact's Phone Number
Emergency Contacts
Person to contact when attempts to reach parents are not successful and who may pick up the child.
Emergency Contact No. 1*
First Last
Emergency Contact No. 1 Home/Cell Phone*
Emergency Contact No. 1 Work Phone
Emergency Contact No. 2*
First Last
Emergency Contact No. 2 Home/Cell Phone*
First Last
Emergency Contact No. 2 Work Phone
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.
Name No. 1
First Last
Phone
Name No. 2
First Last
Phone
Name No. 3
First Last
Phone
Name No. 4
First Last
Phone
Child's Medical Emergency Contact
Physician's Name*
First Last
Physician's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Physician's Phone #*
Dentist's Name (child's or parent's)*
First Last
Dentist's Address*
Street Address Address Line 2 City State ZIP Code
Dentist Phone Number*
Child's Health Insurance
Name of Insurance Plan*
Certificate Number (or ID) #*
Group #*
Policy Holder’s Name
First Last
Special Conditions, Disabilities, Allergies, or Medical Information for Emergency Situations*
Parent/Legal Guardian Consent and Agreement for Emergencies
Parent/Guardian No. 1 Consent Agreement*
As parent/legal guardian, I give consent to have my child receive first aid by facility staff, and, if necessary, be transported to receive emergency care. I understand that I will be responsible for all charges not covered by insurance. I agree to review and update this information whenever a change occurs and at least once a year.
Parent Guardian No. 1 Electronic Signature*
First Last
Today's Date*
MM slash DD slash YYYY
Parent/Guardian No. 2 Consent Agreement
As parent/legal guardian, I give consent to have my child receive first aid by facility staff, and, if necessary, be transported to receive emergency care. I understand that I will be responsible for all charges not covered by insurance. I agree to review and update this information whenever a change occurs and at least once a year.
Parent Guardian No. 2 Electronic Signature*
First Last
Today's Date
MM slash DD slash YYYY

Photo Release

Photo Release for Social Media, Marketing & Media

YES, I give consent to use photos of my child on ALL Social Media sites, marketing materials.
I hereby grant to Therapy and Wellness Connection LLC, the right to interview, Photograph, and/or video record myself or my child and use the photo and/or other digital reproduction of me in any and all of its publications and in any and all other media social/media, whether now known or hereafter existing. I understand and agree that these materials will become the property of Therapy and Wellness Connection LLC and will not be returned. Additionally, I waive any right to any compensation arising or related to the use of the photograph.
No, I do NOT give consent to use photos of my child on ANY Social Media sites or for marketing materials.
I agree to the privacy policy.
Child's Name*
First Middle Last
Parent's Name*
First Middle Last
Date*
MM slash DD slash YYYY

Insurance Intake Form

Client/Child's Name*
First Middle Last
Home Address*
Street Address Address Line 2 City State ZIP Code
Insurance Information
Are you using insurance benefits to cover all or part of therapy services?*
If you are using insurance, indicate whether you are:
Insurance Company Name*
Insurance Company Street Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insurance Company ID #
Group #
Policy Holder's Name
First Last
Policy Holder's Date of Birth
MM slash DD slash YYYY
Policy Holder's Employer
Co-Pay Amount
Have you reached your deductible?
Co-Insurance
Insurance Information Release
Consent to Release Insurance Information
By clicking this box, I hereby authorize Therapy and Wellness Connection to release to my insurance company, any information regarding this dx which is required to process my claims.
Assignment of Insurance Benefits:
Consent for assignment of insurance benefits.
By clicking this box, I hereby assign my insurance benefits to Therapy and Wellness Connection.
Today's Date*
MM slash DD slash YYYY
Name of person filling out this form.*
First Last

Therapy & Wellness Connection Policies & Procedures

Type of Service	Dates/Age of Child	Name of Provider

Relation to child	Diagnosis/Diagnoses

Type of Service	Dates/Ages	Name of Provider

Name	Age	Relation to the child

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