Minor Client Intake

Minor Client Intake
Date: *

Month Day Year
Insurance-Based Services Requested:

Occupational Therapy Speech Therapy Auditory Services Optometric Services Vision Therapy
Private Pay Services Requested:

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

Yes No
If yes, please select date of evaluation:

Month Day Year
Speech evaluation in last year? *

Yes No
If yes, please select date of evaluation:

Month Day Year
Vision exam in last year? *

Yes No
If yes, please select date of exam:

Month Day Year
Hearing exam in last year? *

Yes No
If yes, please select date of exam:

Month Day Year
Areas of concern: *
Client Name: *

First Name Last Name
Date of Birth: *

Month Day Year
Age: *
Gender: *
Contact Information
Parent / Caregiver (1): *

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

First Name Last 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

City State / Province

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

Yes No
Primary language of client: *
Does the child have an IEP at school? *

Yes No
Bring copy to the evaluation? *

Yes No
Medical Information
Allergies / Precautions:
Medical diagnosis:
Date of diagnosis:

Month Day Year
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

City State / Province

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

Month Day Year
Vision Plan? *

Yes No
Policy Number: *
Group Number: *
Policy Holder: *

First Name Last Name
Policy Holder Date of Birth: *

Month Day Year
Secondary Insurance:
Active as of date:

Month Day Year
Policy Number:
Group Number:
Insurance Card Front
Insurance Card Back
Photo ID Front
Photo ID Back
Preferred method of contact: *

Phone Email Text
Best time to contact you: *

Morning Afternoon Evening
Signature: *

Clear
Should be Empty:

Minor Client Intake

Contact Information

Medical Information

Insurance Information