Step By Step/ Sprout Therapy Group
Intake form
Please be sure to click SUBMIT at the bottom of this form.
Parent/ Guardian
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Child's name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Prefer to leave blank/ unknown
Pediatrician (please enter specific name)
*
Do you need an interpreter for non-native English speakers? Please indicate requested language below
*
We do not share or sell SMS opt-in, or phone numbers for the purpose of SMS.
Opt-in to recieve any communication via text:
*
Yes
No
Do you prefer appointment reminders by text or email?
*
Text
Email
Both
How would you like to receive statements?
*
Email
Paper
Has your child ever been seen for outpatient services at Step by Step?
Yes
No
Evaluation Type
*
Physical therapy
Occupational therapy
Speech and language
Feeding
Urgent Breast/Bottle Feeding
Reason for referral/presenting concern
*
Commercial Insurance Carrier
*
Subscriber Name
*
First Name
Last Name
Subscriber Date of Birth
*
-
Month
-
Day
Year
Date
Sex of Subscriber:
*
Female
Male
Unknown
Member ID #
*
Letter Prefix if Applicable, All capital & no spacing
Please add a photo of the FRONT of your child's insurance card here.
Please add a photo of the BACK of your child's insurance card here.
Is there anything else you would like us to know about child child or concerns?
Submit
Should be Empty: