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.

Intake Form for All New Patients

Step 1 of 6

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)

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

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

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

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)

Our Policies & Procedures

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."

Consent to Use Photos/Videos in Marketing Materials(Required)

YES, I give Therapy & Wellness Connection consent to use photos, video, audio of my child for use in marketing & special event promotion materials. Such materials will become the property of Therapy & Wellness Connection, and I waive rights to compensation for current or future use of them.

NO, I do NOT consent to Therapy & Wellness Connection's use of photos, video, or audio of my child in marketing materials or special event promotion.

How did you hear about us?(Required)

Online search

Social media

Brochure, flier, business card, or other printed media

Recommended by friend or family member

Referred by physician or other healthcare provider

Other

If "other" please describe:

Parent/Guardian Electronic Signature(Required)

First Last

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)

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:

Can't finish all at once?

Intake Form for All New Patients

Insurance

Parents & Emergency Contacts

Medical Information

Education

Our Policies & Procedures

Parent Consents & Signature

Let's Connect

Services

About Us