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Intake Forms

The purpose of the Initial Intake Form is to provide Therapeutic Connections with the all information we need to evaluate your child so we may design an inclusive treatment plan based on your child's individual needs. We require information in the following areas:

  • Patient Information
  • Background information
  • Prenatal / Birth History
  • Developmental History
  • Speech - Language Developmental
  • Medical History
  • Educational Background
  • Functional Status
  • Sensorimotor History

The form also covers the Attendance Policy and Payment Policy for Therapeutic Connections.

The Intake Insurance Form is used only for the purposes of Therapeutic Connections insurance and payment obligations. We require information in the following areas:

  • Patient Information
  • Insurance Information

 

Please choose one of the following options:

  • Download and print Adobe PDF forms, fill them out and bring them to your first appointment.
  • Open Microsoft Word forms, fill them out, save document, and return as an email attachment (This email address is being protected from spambots. You need JavaScript enabled to view it. ).