Minor Client Intake

Minor Client Intake
Date:*

MonthDayYear
Insurance-Based Services Requested:

Occupational TherapySpeech TherapyAuditory ServicesOptometric ServicesVision Therapy
Private Pay Services Requested:

The Neuro Integrative ClinicNeurofeedback
*The Neuro Integrative Clinic, Vision Therapy and Neurofeedback are all private pay programs at A Chance To Grow.
OT evaluation in last year?*

YesNo
If yes, please select date of evaluation:

MonthDayYear
Speech evaluation in last year?*

YesNo
If yes, please select date of evaluation:

MonthDayYear
Vision exam in last year?*

YesNo
If yes, please select date of exam:

MonthDayYear
Hearing exam in last year?*

YesNo
If yes, please select date of exam:

MonthDayYear
Areas of concern:*
Client Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Age:*
Gender:*
Contact Information
Parent / Caregiver (1):*

First NameLast Name
Parent / Caregiver Phone Number (1):*
Please enter a valid phone number.
Parent / Caregiver Email (1):*
example@example.com
Parent / Caregiver Name (2)

First NameLast Name
Parent / Caregiver Phone Number (2):
Please enter a valid phone number.
Parent / Caregiver Email (2):
example@example.com
Client Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary language of parent:*
Interpreter needed?*

YesNo
Primary language of client:*
Does the child have an IEP at school?*

YesNo
Bring copy to the evaluation?*

YesNo
Medical Information
Allergies / Precautions:
Medical diagnosis:
Date of diagnosis:

MonthDayYear
Physician in the past year:*
Clinic:*
Clinic Phone Number:*
Please enter a valid phone number.
Clinic Fax Number:
Please enter a valid phone number.
Clinic Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Information
Primary Insurance:*
Active as of date:*

MonthDayYear
Vision Plan?*

YesNo
Policy Number:*
Group Number:*
Policy Holder:*

First NameLast Name
Policy Holder Date of Birth:*

MonthDayYear
Secondary Insurance:
Active as of date:

MonthDayYear
Policy Number:
Group Number:
Insurance Card Front
Insurance Card Back
Photo ID Front
Photo ID Back
Preferred method of contact:*

PhoneEmailText
Best time to contact you:*

MorningAfternoonEvening
Demographic Information
Race - Please check the box that most accurately reflects your race:*

American Indian / Alaskan NativeAsian / Asian AmericanBlack / African / African AmericanCaucasianMiddle EasternNative Hawaiian / Pacific IslanderMore Than One RacePrefer Not to Answer
Ethnicity - Please check the box that most accurately reflects your ethnicity:*

Hispanic / LatinxNon-Hispanic / Latinx
Signature:*

Clear
Should be Empty:

Minor Client Intake

Contact Information

Medical Information

Insurance Information

Demographic Information