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 15-20 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.)

Can't finish all at once?

Click "Save & Continue Later." You'll be provided with a link that will allow you to pick up right where you left off from any other computer within the next 30 days. Enter your email to have the link send directly to your inbox.

Brecksville speech therapy

Intake Form for All New Patients

Step 1 of 6

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