RIA'S HEART ART THERAPY GROUP
$110/MONTH MONDAY'S FROM 4:15-5:15PM
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Diagnoses
Medications/Side Effects
Check all the apply: (Communication)
HOH
Uses Hearing Aids
Wears Glasses
Blind
Aphasic (TBI)
Uses Adaptive Communication Device
Other
Physical
Wheelchair
Walker
Cane
Assistance from Staff to Transfer
Impaired Limb Mobility
Other
Name of School and Grade (If Applicable)
Class:
CDC
Resource
Regular
Type option 4
Reading Abilities
Math Abilities
Behavior
Other Therapies Received
Contact Person Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Preferred Type of Communication
Phone Call
Text Message
Email
Mail
Reason for Referral
Quality of Life
Emotional/Mental Health
Cognitive/Academic
Fine Motor Skills
Gross Motor Skills
Range of Motion
Sensory Needs
Adaptive Lessons
Communication
Socialization
Strength and Endurance
Agitation/Behavioral Concerns
Other
Co-Treat with Other Therapies
PT
OT
SLP
Counseling
Other therapist(s) Name and Number:
Art Background
Drawing
Painting
Coloring
Clay
Legos
Other types of sculpture
Computer art
Drawing along with art tutorials
Other
Other Comments:
Responsible Payer
First Name
Last Name
Responsible Payer Signature
PAYMENTS CAN BE MADE BY CHECK OR CREDIT CARD
TO PAY, YOU CAN MAIL A CHECK TO 1119 OLD HUMBOLDT RD JACKSON,TN 38305 OR CALL MISTY HART AT (731)554-5150 TO PAY WITH A CREDIT CARD
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