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Mala Child and Family Institute OT Enrollment Form
Please complete & submit this form to receive Occupational Therapy services. Our OT department operates out of our Ann Arbor location & virtually.
20
Questions
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1
Who will be receiving services?
*
This field is required.
We offer OT to all ages, children and adults.
Me
My Child
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2
Has any member of your immediate household ever received care at Mala?
*
This field is required.
No
Yes, Medication Management
Yes, Psychotherapy
Yes, Psychological Evaluation
Yes, School Advocacy
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3
Your Name
*
This field is required.
If you are a parent or guardian, put your name here.
First Name
Last Name
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4
Child's Name
If under 18 years old
First Name
Last Name
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5
Phone Number
*
This field is required.
Please enter a valid phone number.
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6
Email
*
This field is required.
example@example.com
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7
Address
*
This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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8
Date of Birth of the Client
*
This field is required.
This is the date of birth of the person you are seeking care for.
-
Date
Year
Month
Day
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9
Contact #2 Name
*
This field is required.
*If this is a divorced or separated household this MUST be the second parent.
First Name
Last Name
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10
Contact #2 Email
*
This field is required.
*If this is a divorced or separated household this MUST be the second parent.
example@example.com
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11
Contact #2 Phone Number
*
This field is required.
*If this is a divorced or separated household this MUST be the second parent.
Please enter a valid phone number.
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12
What is Contact #2's relation to you or your child?
*
This field is required.
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13
Who is your insurance carrier?
*
This field is required.
Our OT department is in network with Blue Cross Blue Shield and Blue Care Network.
Blue Cross Blue Shield
Private Pay - Out of Pocket
Blue Care Network
Other
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14
Upload photos of insurance card (front and back), if applicable
*
This field is required.
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
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15
Primary Insured's Date of Birth
*
This field is required.
-
Date
Year
Month
Day
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16
What services is the potential client interested in?
*
This field is required.
Sensory processing differences (sensory-based motor skills/motor planning skills, sensory discrimination, self-regulation skills)
Neuromotor processes
Executive functioning skills
Gross motor skills
Fine motor skills
Visual motor skills/ocular motor function
ADLs (Activities of Daily Living/Self-Care Skills)
Social emotional development
Feeding challenges
Parent Coaching
School Advocacy
Instrumental Activities of Daily Living (e.g., meal prep, grooming, bathing, feeding, toileting, medication, financial management, mobility)
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17
What is the potential client's schedule availability?
*
This field is required.
Please indicate
all
possibilities.
I am flexible, first available.
Monday Morning (9am-12pm)
Monday Afternoon (12pm-3pm)
Monday Evening (3pm-8pm)
Tuesday Morning (9am-12pm)
Tuesday Afternoon (12pm-3pm)
Tuesday Evening (3pm-8pm)
Wednesday Morning (9am-12pm)
Wednesday Afternoon (12pm-3pm)
Wednesday Evening (3pm-8pm)
Thursday Morning (9am-12pm)
Thursday Afternoon (12pm-3pm)
Thursday Evening (3pm-8pm)
Friday Morning (9am-12pm)
Friday Afternoon (12pm-3pm)
Friday Evening (3pm-8pm)
Saturday Morning (9am-12pm)
Saturday Afternoon (12pm-3pm)
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18
Who referred you to Mala Occupational Therapy or how did you hear about us?
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19
Have you been diagnosed with anything and who made the diagnoses?
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20
OT Prescription
Please upload the prescription. We need a copy of this before your intake session. You primary care or referring provider can also fax us the prescription to (734) 353 - 4298. This prescription must be from a medical doctor.
Drag and drop files here
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Max. file size
: 10.6MB
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