New Patient Intake Form
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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

  • Child's date of birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date form completed:
     - -
  • What services are you interested in?*
  • Preferred times- Mondays*
  • Preferred times- Tuesdays*
  • Preferred times- Wednesdays*
  • Preferred times- Thursdays*
  • Preferred times- Fridays*

  • II. Family History

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  • III. Child's Social History

  • IV. Educational History

  • V. Therapy History

  • Has your child received services in the past?*
  • Has an assessment been completed in the last 6 months?*

  • VI. Birth History

  • Is your relationship to the child:*
  • Delivery:
  • Passed newborn hearing screen:
  • Mother's pregnancy:*
  • Child's delivery:*
  • Child's condition at birth:*

  • VII. Other Pertinent Medical History

  • Do any of the following apply to your child?

  • 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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  • Should be Empty: