Information Request Form

Service Inquiry for Insurance Form of Payment
How did you hear about us? How did you hear about us?
Referring physician? Referring physician?
Child's Name

First NameLast Name
Child's date of birth

MonthDayYear
Date
1st Parent's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
2nd Parent's Name

First NameLast Name
Phone Number

Area CodePhone Number
E-mail
Best time to contact you? Best time to contact you?
Insurance Information
Name of insured:   Name of insured   Date of birth:   Date of birth
Relationship to patient:   Relationship to patieint
Insurance company:   Insurance company   ID#   ID#
Number for providers (Located at back of card):   Number for providers

Information About Your Child
Verbal?

YesNo
Able to follow directions?

YesNo
Has difficulty transitioning away from parent?

YesNo
Ambulatory

YesNoWalks with assistive equipment
Parent's concerns

HandwritingFine Motor CoordinationAttentionSensory ProcessingMuscle WeaknessGross Motor CoordinationOther
Has your child received OT before?

YesNo
Child is receiving the following additional services:

Occupational TherapyPhysical TherapySpeechABAEarly InterventionOther
Parent's Availability
Mon Mon
Tue Tue
Wed   Wed
Thu   Thu
Fri   Fri
Sat   Sat
Upload 1)Picture of insurance card (front & back) 2) Copy of doctor's prescription for OT

Browse Files

Cancelof
Should be Empty:

Service Inquiry for Insurance Form of Payment