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  • New Patient Intake Form

    Thank you for your interest in our clinical services. To help us better serve you, please provide us with the information requested below. Please be assured that this information will be held confidential, and is necessary for the RPTA staff to determine the most appropriate evaluation and therapy services. A copy of our Notice of Privacy Practices is also available upon request.
  • I. General Information

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  • II. Family History

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  • III. Child's Social History

  • IV. Educational History

  • V. Therapy History

  • VI. Birth History

  • VII. Other Pertinent Medical History

  • VIII. Developmental History

    You may record here any previous developmental concerns, hospitalizations, or other events that have occurred.
  • IX. Current Skills

    -Sensory Processing
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