Intake Form

New Patient Intake

Please click the save button at the bottom of the page if you need to leave the form and come back to it later.
Date

MonthDayYear
Date
Child's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Current Date

MonthDayYear
Age
Sex

MF
Parent/Guardian 1*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email address*
1
Parent/Guardian 2

First NameLast Name
Phone Number
Please enter a valid phone number.
Email address
Address of Parent 2 (if different from child)

Add address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us? Please be specific and include the name of the person who referred you to us. We'd like to express our gratitude to them!*
If it's a doctor, please write name and address of the provider:
Please describe your specific concerns in requesting an evaluation/services for your child:*
Does your child have a formal diagnosis?*

YesNo
If yes, what is it?
When was it made?
Type of service needed:

Evaluation (an evaluation is needed to begin therapy)Social Groups (No evaluation needed for Social Groups)Therapy (Child was recently evaluated; Please upload report below)Consult
Type of evaluation(s) needed:

SpeechLanguageOccupational TherapyFeedingLiteracyAugmentative Alternative Communication (AAC)Other
Type of therapy needed:

SpeechLanguageOccupational TherapyFeedingLiteracyAugmentative Alternative Communication (AAC)Other
If your child has already been evaluated and/or has received evaluations pertinent to your concerns please upload them here. This information is very helpful in our ability to make evaluative and therapeutic decisions.

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Location:

Summit officeMontclair office (We currently provide Speech/Language and Feeding services)
What do you hope to gain from our services?
What are your goals and aspirations for your child?
Has your family experienced any recent crisis or stress that you feel is impacting your child's development at this time?

Please fill in your child's availability to receive therapy for each day between the hours of 7:30 am and 7:00 pm (Please note, our office hours are until 5:30 PM on Fridays and 3:00 PM on Saturdays). Remember to allow for travel time. If your child is not available on a particular day, please indicate "not available". Please give as much information as you can, as this will support our ability to place your child for therapy if needed.*

	Availability for Therapy (Start time- End time)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Please note that CSS is in-network with Cigna and Aetna for services for speech-language/AAC and feeding therapy. We are happy to bill your out-of-network provider for all other services. We are not certified to bill Medicaid.
Insurance Information*

*Please provide a copy of your insurance card (front & back) for all insurance companies.
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Insurance CO: Insurance CO
ID#: ID #
Group #:   Group #
Policy Holder's Name:   First Name*   Last Name*
Policy Holder's Date of Birth:   DOB*
Signature
Should be Empty:

New Patient Intake