INTAKE / APPLICATION / REFERRAL FORM
Date of Intake:
Date of Order:
Patient ID #:
*
Patient Name:
*
Date of Birth:
Address:
Zip:
City:
*
Home Phone:
Sex:
Female
Male
Cell Phone:
Mother’s Name:
Father’s Name:
Guardian:
Relationship:
Work Phone:
Alternate:
Other Relative:
Relation:
Phone:
Insurance Company:
Name of Insured:
Address:
Phone:
Policy #:
Group #:
Social Sec (Insured’s):
Child’s Social:
Services Requested:
PT
OT
ST
Diagnosis
1.
Date:
2.
Date:
3.
Date:
4.
Date:
Do you understand your child’s diagnosis?
Yes
No
If No, what questions do you have?
Precautions/Contraindications:
Please list all known allergies:
Does your child have any food allergies?
Has anyone in your family been developmentally delayed?
How does your child communicate his/her wants or needs?
GENERAL INFORMATION
What languages does the child speak? What is the child’s primary language?
What languages are spoken in the home? What is the primary language spoken?
Describe your concerns regarding your child’s physical therapy (PT), occupational therapy (OT) and/or speech-language therapy (ST) needs:
When was the problem first noticed?
FAMILY
Number of siblings
Live in a?
House
Apartment
What floor
Stairs?
Yes
No
With whom does the child live?
GENERAL INFORMATION
Is child adopted?
Yes
No
Is child in foster care?
Mother's general health during pregnancy (illness, accidents, medications, etc.)
Mother's age at time of birth
Number of Children
Number of Pregnancies
Did mother receive prenatal care?
Length of pregnancy (in weeks)
Check type of delivery
Vaginal
Caesarian
Birth weight
General condition of child immediately following birth
Was child in NICU or hospitalized? If yes, please explain.
Please describe any unusual conditions that may have affected the pregnancy or birth.
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