Intake Form for All New Patients

Includes information on:

  • Insurance
  • Parent contacts
  • Emergency contacts
  • Medical history
  • Education
  • Therapy & Wellness Connection's Policies & Procedures

Expect to spend about 20-25 minutes on this form. We recommend completing it on a desktop or laptop, rather than a smartphone, as it's lengthier and includes several requests for document uploads. Be sure to fill out all "Required" fields before you click "Submit."

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

  • Health insurance card(s)
  • Parent & emergency contact phone numbers, emails, addresses, etc.
  • Medical provider(s) contact information
  • Medical history (diagnoses, surgeries, illnesses, prescriptions, therapies, etc.) & corresponding medical records/assessments for conditions relevant to the therapy services being sought
  • School records (IEP, 504 plan, ETR, etc.)
Brecksville speech therapy

Intake Form for All New Patients

Child's Name(Required)
Child's Date of Birth(Required)
Child's Address(Required)
Name of person completing this form:(Required)

Insurance

Are you using health insurance benefits to cover all or part of the child's therapy services?(Required)
If none, type N/A
If none, type N/A. If unsure, say, "I don't know."
Max. file size: 195 MB.
Max. file size: 195 MB.
Max. file size: 195 MB.
Max. file size: 195 MB.
Consent to release insurance information & assignment of benefits.(Required)

Parents & Emergency Contacts

Parent 1 Name(Required)
Parent 1 Home Address(Required)
If none, leave blank.
Parent 1 Employer Address
If none, leave blank.
Parent 2 Name
If Parent 2 section not applicable, leave entries blank.
Parent 2 Home Address
Parent 2 Employer Address
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.
Persons Authorized to Pick Up Child(Required)
Name
Phone Number
Email
Relationship to child
 
List adults authorized to pick up your child.
Who else lives at home with your child?(Required)
Name:
Age:
Relationship to the child:
 
For each additional person, click the "plus" to the right to create another row.
If none, write "N/A" for not applicable.
If none, write N/A

Medical Information

Primary Care Doctor's Name(Required)
Primary Care Doctor's Address(Required)
If none, leave blank.
Examples of pediatric specialists include: Cardiologist, Neurologist, Psychiatrist, Psychologist, Oncologist, Nephrologist, Pulmonologist, Gastroenterologist, Orthopedic Surgeon, Immunologist, Rheumatologist, Infectious Disease Specialist, Urologist, Audiologist, Intensivist, etc.
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.
Therapies: List all therapies your child has previously received, including Speech Therapy, Occupational Therapy, Physical Therapy, ABA/Behavior Therapy, Counseling, Psychiatric Treatment, etc.
Therapy / Treatment type:
Dates received:
Name of clinic/provider:
 
Drop files here or
Accepted file types: jpg, pdf, png, Max. file size: 195 MB.
    Consent for Emergency Medical Treatment(Required)
    Has your child's hearing been tested by an audiologist?(Required)
    If your child's hearing has been tested, what were the results?

    Education

    Is your child attending any of the following?(Required)
    Check if your child has any of the following:(Required)
    Check if your child receives any of the following services at school:
    Accepted file types: jpg, png, pdf, Max. file size: 195 MB.

    Our Policies & Procedures

    Page: /

    Parent Consents & Signature

    You're almost done! Carefully read these acknowledgements & consents before clicking. Make sure you've filled out all required fields of the Intake Form before you click "Submit."
    Acknowledgement of Our Policies & Procedures(Required)
    Consent to Use Photos/Videos in Marketing Materials(Required)
    Therapy & Wellness Connection may seek to interview, photograph, or video record parents and/or patients for purposes of marketing our services or promoting special events. By checking "YES," you confirm that you understand and agree that these materials will become property of Therapy & Wellness Connection. Further, you recognize that these materials may not be shared with/returned to you, and you waive any right to compensation for current or future use of them.
    How did you hear about us?(Required)
    Parent/Guardian Electronic Signature(Required)
    By providing this electronic signature, I hereby affirm I am the parent/guardian of the aforementioned child, for whom I am legally authorized to make medical decisions. I agree to each of the above conditions as indicated, and certify all information contained in this form is complete and accurate to the best of my knowledge. I understand that an electronic signature is the legal equivalent of my manual/handwritten signature, and I am agreeing to all terms and conditions as indicated in this form.
    Today's Date(Required)