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Child's Name*

DOB*

Parent's Full Name*

Home address*

City*

Zip*

Primary phone*

Secondary phone

How did you find out about the Children's Center?*

Primary care physician
(first and last names)

Does your child have a diagnosis?

Services Requested
(PT, OT, SLP)
Physical Therapy Occupational Therapy Speech Therapy Social Skills

What are the main concerns you have for your child?

Have you received therapy services for this problem in the past? (What type, when, from whom?)

Is it okay for Children's Center for Therapy to leave messages on your answering machine?*

Please note that you will be asked about your insurance information when Children's Center for Therapy contacts you regarding this intake form.