INTAKE FORM

INTAKE FORM
2653 Canton Road, Marietta, GA 30066 929-496-6435 I AllofTOT@gmail.com I www.all-of-t.com
Childs Full Name
Date of Birth

MonthDayYear
Date
Other
Age
Address
Parent/Guardian Name(s): Phone Number(s):
ParentGuardian Names
Email
Email
example@example.com
SECTION 2: REFERRAL & DOCTOR INFORMATION
Referring Provider: Pediatrician / Primary Care Physician: Phone Number: Fax
Referring Provider
Pediatrician Primary Care Physician
Address for Pediatrician
Reason for Referral
Fax
SECTION 3: INSURANCE INFORMATION
Primary Insurance Company: Member ID #:
Primary Insurance Company
Member ID
Group
Policy Holders Name
DOB
Relationship to Child
Employer
Secondary Insurance if any
DEVELOPMENTAL HISTORY & MILESTONES
Demographics: Who does your child live with?
At what age did your child ? Roll over ________________. Sat independently ______________________ I Crawled ______________ Walked independently ______________ Used first words _____________ Combined two words ______________ Toilet trained ________________ Dressed self ___________________ Fed self with utensils Hand preference noticed Writes recognizable shapes
Is your child a picky eater?
SENSORY PROCESSING & REGULATION
Sensory Processing skills? Touch/Tactile: Avoids messy play Constantly touches objects Sensitive to tags, Enjoys tight hugs , Movement/Vestibular: Fearful of swings Constantly moving , Difficulty sitting still , Enjoys jumping Auditory: Covers ears Startles easily, Talks loudly , Distracted by noise
Community participation
Home routines/behavior:
Home routinesbehavior
SchoolGrade
Teacher
School location
Extracurricular activities
Any classroom concerns
Does your child have an IEP504 Yes No Date updated

MonthDayYear
Date
Preferred site

ABA CLINICCanton Road OfficeSchool
Other preferences home school telehealth
Current/past therapies or diagnoses: Strengths, interests, motivators:
medical history/family history
Strengths interests motivators
I certify that the above information is accurate and authorize All-Of-T to contact providers for coordinated care. Parent/Guardian Signature: Date:
Date

MonthDayYear
Date
File Upload

Cancelof
Upload a copy of insurance cards front and back, as well any additional supporting docs.
SECTION 8: SCHEDULING & LOCATION Preferred Days: Mon Tues Wed Thurs Fri Sat Preferred Time: Morning Afternoon Evening Can travel to 2653 Canton Road office? Yes No Sometimes
Should be Empty:

INTAKE FORM

DEVELOPMENTAL HISTORY & MILESTONES

SENSORY PROCESSING & REGULATION