Evaluation Enrollment Form

1
Who will be receiving services?* This field is required.We offer occupational therapy services for infants, children, teens, and adults.
My child
Me
2
Has any member of your immediate household ever received care at Mala?* This field is required.
Yes
No
3
Your Name* This field is required.If you are a parent or guardian, please put your name here.
First Name
Last Name
4
Your relationship to client. * This field is required.Write "self" if you are requesting care for yourself.
5
Client Name (If under 18)
First Name
Last Name
6
Client's Date of Birth* This field is required.
Date
Month
Day
Year
7
Phone Number* This field is required.
Please enter a valid phone number.
8
Email* This field is required.
example@example.com
9
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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
10
Is client a child in a divorced or separated household?* This field is required.
YESNO
11
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
12
Contact #2's relation to client* This field is required.
13
Contact #2 Email* This field is required.*If this is a divorced or separated household this MUST be the second parent.
example@example.com
14
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.
15
Who is your insurance carrier?* This field is required.We are in-network providers with Blue Cross Blue Shield (BCBS) and Blue Care Network (BCN) for occupational therapy. You can review our private pay fees on our website.
Blue Cross Blue Shield(BCBS)
Paying out of pocket
Blue Care Network (BCN)
16
Upload photos of insurance card (Front and Back)* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
17
Primary Insured Date of Birth* This field is required.
Date
Month
Day
Year
18
What services are you seeking?* This field is required.
Sensory processing differences
Neuromotor processes
Executive functioning skills
Gross motor skills
Fine motor skills
Visual motor skills/ocular motor functions
Activities of Daily Living (ADLs) / Self-Care Skills
Social emotional development
Feeding and eating challenges
Parent coaching
School advocacy
Instrumental Activities of Daily Living (meal prep, grooming, bathing, feeding, toileting, medication, financial management, mobility)
Other
19
What is the client's available time to meet for weekly sessions?* This field is required.It is crucial you list accurate availability. We can offer a note if client needs to miss school or work to attends sessions. We strongly recommend consistency in care to meet treatment goals.
20
Any previous diagnoses received:* This field is required.
Autism Spectrum Disorder (ASD)
Attention-Deficit/Hyperactivity Disorder (ADHD)
Sensory Processing Disorder (services not always covered by BCN on its own, but often tied to another diagnosis)
Developmental Coordination Disorder (DCD)
Specific Learning Disabilities (when impacting motor, sensory, or self-regulation skills)
Down Syndrome or other genetic conditions
Cerebral Palsy and other neurological conditions
Trauma- or stress-related disorders (if impacting daily functioning)
Feeding and swallowing disorders
Stroke (CVA) or Traumatic Brain Injury (TBI)
Multiple Sclerosis (MS), Parkinson’s disease, or other progressive neurological conditions
Orthopedic injuries or post-surgical recovery (e.g., hand therapy, joint replacement)
Chronic pain or arthritis affecting daily living
Mental health diagnoses (e.g., anxiety, PTSD, depression) when they significantly impact self-care, work, or daily function
Other
Other
21
OT PrescriptionPlease upload the prescription. We need a copy of this before your intake session or we will not be able to start care. Your primary care or referring provider can also fax us the prescription to (734) 353 - 4298. This prescription must be from a medical doctor. *Please note, a prescription of services is NOT needed for private-pay clients.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
22
How did you hear about our services?* This field is required.
Should be Empty: