Client Intake Form
Child Information
Child Name
*
First Name
Last Name
Child Preferred Name (Called)
Child Date of Birth (DOB)
*
-
Month
-
Day
Year
Date
Primary Caregiver and Communication
Primary Caregiver Name
*
First Name
Last Name
Primary Caregiver Contact Info
*
Primary Language Spoken
*
Translation Needed
Yes
No
Presenting Concerns and Background
Main concerns with your child
*
When did you begin having these concerns?
*
Child's strengths
Child's challenges
Diagnoses and Special Services
Does your child have any diagnoses?
*
No
Yes
If yes, please specify diagnoses
Special Services Currently Receiving
Special Ed
Speech
OT
PT
Other
Primary Insurance Information
Primary Insurance Company
*
Primary Insurance Plan
Primary Insurance Group Name/Number
Primary Insurance Member ID
*
Primary Insurance Coverage From
*
-
Month
-
Day
Year
Date
Primary Insurance Coverage Until
-
Month
-
Day
Year
Date
Secondary Insurance Information
Secondary Insurance Company
*
Secondary Insurance Plan
Secondary Insurance Group Name/Number
Secondary Insurance Member ID
Secondary Insurance Coverage From
-
Month
-
Day
Year
Date
Secondary Insurance Coverage Until
-
Month
-
Day
Year
Date
Insurance Card Upload and Consent
Upload copies of the front and back of all insurance cards
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Consent for insurance verification and service authorization
*
I consent for communicating with the insurance carrier to verify benefits and authorize services
Math Challenge
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