Physical Therapy Intake

Fill out the following form for pediatric physical therapy intake. All sections marked "Required" must be completed before you submit.

Complete this intake form if your child has been referred for physical therapy.

Child's Name(Required)

First Last

Does the child have a nickname?

Child's Date of Birth(Required)

Explain any developmental delays your child is experiencing or has experienced in the past.(Required)

Explain any physical limitations your child has AND/OR concerns you have about their mobility, strength, coordination, healthy growth, etc.(Required)

List any special equipment your child uses, such as splints, braces, adaptive utensils, or other.(Required)

If none, write N/A (not applicable).

What are the primary concerns that led you to seek physical therapy?(Required)

What are your - and/or your child's - goals with physical therapy?(Required)

What would you say are your child's strengths?(Required)

Tell us what days, times, and location would be ideal for Physical Therapy. (Ex: Anytime Monday-Thursday, 8a-3p, in-clinic/at home, etc.)*(Required)

While we cannot guarantee our availability will match your desired schedule exactly, we'll do our best!

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 you answered "other" to the previous question, please describe:

Parent Phone #(Required)

What's the best way to reach you?

Parent Email(Required)

Parent Electronic Signature(Required)

First Last

By providing this electronic signature, I hereby affirm I am the parent/guardian of the abovementioned child, for whom I am legally authorized to make medical decisions. I agree that the information contained in this form is complete and accurate to the best of my knowledge.

Today's Date(Required)

Physical Therapy Intake

Physical Therapy Intake

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