Website Intake Form

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How did you hear about TLC?

PediatricianSocial MediaWebsiteExisting PatientOther
Date

MonthDayYear
Date
Which location would you prefer to go to

RoswellKennesaw
Patient Information
Client’s Name
Client's DOB

MonthDayYear
Date
Client’s Gender

BoyGirlOther
Primary Language
Other Language(s)
Parent(s)/Gaurdian(s) Name(s):
Lives w/ both parents?

YesNo
Parent’s Email*
example@example.com
Parent’s Phone #*
Address
Pediatrician
Other Provider (SLP, OT, Psych, etc)
Has your child been diagnosed with

Autism?ADHD?Dyslexia?Other?
Insurance Information
Primary Insurance
Insurance ID
Primary Subscriber Name
Primary Subscriber DOB
Does your child have a secondary insurance?

YesNo
Secondary Insurance
Insurance ID
Secondary Subscriber Name
Secondary Subscriber DOB
Services Information
Interested in:

Speech TherapyFeeding TherapyOccupational TherapyABA in ClinicABA in SchoolOther
Has your child had any of the following?

Evaluation in last 6 monthsServices at another facility in last 6 months
Where were their evaluation(s) in last 6 months and for what therapy?
Where were their services in last 6 months and for what therapy?
Does your child have any of the following documentation?

IEP Hearing Screening Psychological Evaluation (w/i 3 yrs) Recent Evals:Hearing ScreeningPsychological Evaluation (w/i 3 yrs)Recent Evals:
Any other pertinent documentation:
Reasons for Seeking Therapy
Is your child talking like their peers?

YesNo
Does your child understand questions most of the time?

YesNo
Is your child able to follow directions?

YesNo
Is your child NOT able to say any of their speech sounds correctly?

YesNo
Any other Notes/Concerns:
Should be Empty:

Patient Information

Insurance Information

Services Information

Reasons for Seeking Therapy