Intake Form for All New Patients

Child's Name(Required)

First Last

Child's Date of Birth(Required)

Child's Address(Required)

Street Address Address Line 2 City State ZIP Code

Name of person completing this form:(Required)

First Last

Relationship to the child:(Required)

Insurance

Are you using health insurance benefits to cover all or part of the child's therapy services?(Required)

Yes

No

I'm not sure

Name of Insurance Company(Required)

If none, type N/A

Policy # / Subscriber ID(Required)

If none, type N/A. If unsure, say, "I don't know."

Front of Insurance Card 1

Max. file size: 195 MB.

Back of Insurance Card 1

Max. file size: 195 MB.

Secondary Insurance Company

Secondary Policy # / Subscriber ID

Front of Insurance Card 2

Max. file size: 195 MB.

Back of Insurance Card 2

Max. file size: 195 MB.

Parents & Emergency Contacts

Parent 1 Name(Required)

First Last

Parent 1 Phone Number(Required)

Parent 1 Email(Required)

Parent 1 Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Parent 1 Employer Name

If none, leave blank.

Parent 1 Employer Phone Number

Parent 1 Employer Address

Street Address Address Line 2 City State ZIP Code

If none, leave blank.

Parent 2 Name

First Last

If not applicable, leave blank.

Parent 2 Phone Number

Parent 2 Email

Parent 2 Home Address

Street Address Address Line 2 City State ZIP Code

Parent 2 Employer

Parent 2 Employer Phone Number

Parent 2 Employer Address

Street Address Address Line 2 City State ZIP Code

Emergency Contact(s)(Required)

Name

Phone Number

Email

Relationship to child

Persons NOT in your immediate family who we should contact if attempts to reach parents/guardians are unsuccessful. For each additional person, click the "+" symbol to create another row.

Persons Authorized to Pick Up Child(Required)

Name

Phone Number

Email

Relationship to child

List adults authorized to pick up your child. For each additional person, click the "+" symbol to create another row.

Who all lives in the home with your child?(Required)

Name:

Age:

Relationship to the child:

For each additional person, click the "+" symbol to the right to create another row.

Are there any other languages spoken in the home? If yes, which language(s)? Spoken by whom and how often?(Required)

If none, write "N/A" for not applicable.

Are there any family circumstances that would be helpful for our staff or therapists to know? (Examples: Child custody arrangements, protection orders, chronic illness of a parent or sibling, etc.)(Required)

If none, write N/A

Medical Information

Primary Care Doctor's Name(Required)

First Last

Primary Care Doctor's Phone Number:(Required)

Primary Care Doctor's Address(Required)

Street Address Address Line 2 City State ZIP Code

If there are medical providers aside from your child's primary care doctor who should be contacted in the event your child has a medical emergency, please provide us with their information here.

If none, leave blank.

Pediatric Specialists: Has your child ever been treated by a pediatric specialist? If NO, write "N/A." If YES, please name the specialist & details of that treatment.(Required)

Examples of pediatric specialists include: Cardiologist, Neurologist, Psychiatrist, Psychologist, Oncologist, Nephrologist, Pulmonologist, Gastroenterologist, Orthopedic Surgeon, Immunologist, Rheumatologist, Infectious Disease Specialist, Urologist, Audiologist, Intensivist, etc.

Describe any serious illnesses, traumatic injuries, or significant/chronic medical conditions your child has experienced. Indicate whether surgery or hospitalization was required.(Required)

If none, write N/A.

Allergies: If your child has allergies, please tell us what those are, your child's reaction to those allergens, and what medications (if any) are used to prevent/counteract adverse allergic reactions.

Allergy:

Reaction:

Medications:

If none, leave blank.

Medications: List any medications prescribed to your child, the condition for which it's prescribed, and frequency/dosage.

Medication:

Prescribed for:

Dosage:

Frequency:

If none, leave blank.

Diagnoses: List any developmental, behavioral, neurological, cognitive, or psychiatric condition your child has been diagnosed with and/or treated for. Indicate diagnosis date and whether treatments are ongoing.

Diagnosis:

Date of diagnosis:

Is treatment ongoing (yes/no)?

If none, leave blank.

List all other services your child is receiving/has received, including speech therapy, occupational therapy, physical therapy, ABA/behavior therapy, counseling, psychiatric treatment, etc.(Required)

Upload copies of any relevant medical/therapy assessments, diagnoses, medications, plans of care, etc.

Drop files here or

Accepted file types: jpg, pdf, png, Max. file size: 195 MB.

Has your child's hearing been tested by an audiologist?(Required)

Yes

No

Not Sure

If your child's hearing has been tested, when/where did testing take place?

If your child's hearing has been tested, what were the results?

Passed.

Did not pass.

Inconclusive.

I'm not sure.

Are there any other medical or developmental concerns not detailed elsewhere in this form about which we should be aware? Answer Yes/No. If YES, please describe.(Required)

What Services Are You Hoping to Secure for Your Child?

At TWC, we focus on client-centered care and encourage our families to build the care plan that works best for them! As such, we provide several programs that permit caregivers to enroll their children in the plan that best suits their needs. Please review the programs below and check the one that you’d like your child to be enrolled in.(Required)

REDWOOD: Full program - ABA, education & therapy (OT, PT or ST)

PINE: ABA & therapy (OT, PT or ST)

ELM: ABA & education (academic tutoring & homeschooling program)

BONSAI: ABA only

MAGNOLIA: therapy only (OT, PT or ST)

WILLOW (education only)

To confirm your plan of care selection, please type the title of it here:

Intake Form for All New Patients

Intake Form for All New Patients

Includes information on:

Records/information you may want to have handy before you start:

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