Occupational Therapy Initial Intake Form

Child's Name*

Date of Birth*

Age*

Grade*

Caregiver's Name*

Relationship*

Caregiver Cell Phone*

Area Code Phone Number

Home Phone

Area Code Phone Number

Additional Caregiver's Name

Relationship

Additional Caregiver Cell Phone

Area Code Phone Number

Home Phone

Area Code Phone Number

Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Email*

example@example.com

Preferred Contact Method

Insurance and Member ID (Submit Photo Below)*

Insurance Subscriber Name and DOB*

Pediatrician's Name

Pediatrician's Address and Phone Number*

Any complications during pregnancy or birth

Please list all past surgeries and major injuries with dates

Please list any medical conditions or diagnoses *

Is your child taking any medications?

Primary Concerns*

Does your child currently receive OT/PT?*

YesNo

If yes, what was the date of the last evaluation?

Does your child wear glasses?*

YesNo

Does your child prefer one hand over the other?*

LeftRightNo Preference

Does your child like to run?*

YesNo

Does your child know how to ride a bike?*

YesNoYes, with training wheelsAble to ride a trike

Do you consider your child clumsy, showing poor control of body movements or having difficulty learning new motor skills?*

YesNo

Please write the age your child achieved each milestone:

Rolled

Crawled

Walked

Jumped

Reached

Finger Feed

Eat with Spoon

Dress Self

Toilet Trained

Clothing Fastener

Draw Circle

Cut with Scissors

Use Knife for Cutting

Drink from Open Cup

Self Care Skills*

	Dependent	Needs Assistance	Independent
Feeding
Grooming
Toileting
Eating
Upper Body Dressing
Lower Body Dressing
Bathing
Sleep
Buttons
Zipper
Tie Shoes
Puts on Socks/ Shoes
Takes off Socks/ Shoes
Opens Snack Pack
Opens Water Bottle

Please list any concerns regarding self-care skills

Describe your child at present*

*

Does your child have difficulties with sleep?*

YesNo

What are your child's favorite activities?

What does your child dislike the most?

Are any of your family's everyday activities affected? If so, how?

Please provide any additional information you would like us to know

Please list all potential availability for evaluation and appointments. (Days and Times)*

Preferred Office Location

23 Kilmer DriveBuilding 1, Suite B Morganville, NJ104 Interchange Plaza Monroe, NJ 088311Princeton Office

To ensure a smooth course of Occupational Therapy treatment for your child, please review our payment and appointment policies and ask any questions you may have.

1. Insurance: We participate in some insurance plans and as a courtesy will bill your primary insurance carrier if you provide all necessary information including an up to date insurance card. If you have insurance with a plan we do not participate in, or do not have insurance, payment in full for each visit is required at the time of the visit. Please note that knowing your insurance benefits and limitations is your responsibility. Please contact your insurance company to verify number of visits, co-pay amount, deductible, need for referral or letter of medical necessity, authorization, precertification, exclusions, etc.

2. Co-payments and deductibles: All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company.

3. Non-covered services: Please be aware that some, or perhaps all, of the services you receive may not be covered by your insurance carrier. Insurance carriers and their policies differ widely in terms of what diagnoses and procedures they will cover. Please note that any non-covered services are your responsibility.

4. Claims submission: We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly and we will assist you in providing that information at your request. Payment for services is your responsibility
whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company, we are not a party to that contract.

5. Coverage changes: If your insurance changes, please notify us before your visit so that we can make the appropriate changes to help you receive your maximum benefits. In the event that you do not notify our
office in a timely manner and your insurance is expired, you will be responsible for any unpaid claims.

CANCELLATIONS, LATE ARRIVALS; CANCELLATION FEES:

1. Cancellations for any reason other than the client’s illness, must be made with 24 hours notice or a $50.00 cancellation fee will be charged. Insurance cannot be billed for this fee. Advance notice allows us to offer the appointment to another client, as well as notify the OT.

2. Cancellations for a client’s illness must be made by 9 am the day of their appointment. Any call outs for illness made after 9 am will be charged a cancellation fee. Cancellation for the illness of a parent, spouse, family member or sibling will also incur a cancellation fee.

3. If you are late to an appointment, we will need to conclude the session at the usual time. If your therapist is running late for any reason, you will be given your full session time. We regret any resulting inconvenience to your personal schedule.

ATTENDANCE POLICY:
1. You are asked to maintain attendance that keeps you in good standing with our
attendance policy. This allows us to maintain a consistent and quality therapy program, and to maximize your child’s progress and to avoid regression of skills.

2. Clients who miss 2 consecutive sessions, without calling us and do not return our calls regarding the absences, will be removed from our schedule. We will assume that you are terminating therapy for your child. You will, however, be charged the full amount of your final two sessions.

You will be contacted to set up an evaluation. We look forward to hearing from you!

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