CLINIC-BASED AND TELEHEALTH

O C C U P A T I O N A L T H E R A P Y

Services to support your child's developmental needs

For New Patients

Your Name

Child's Name

Email Address

Phone Number

Insurance Type

Diagnosis

Pediatrician's Name

Child's Date of Birth

Address Line 1 (Street Address)

Address Line 2 (City, State)

Insurance ID

Name of School (if in school)

Pediatrician's Phone Number

Services received in school:

Reason for Requesting Services

Other Private Services Received

ABA Therapy

Speech Therapy

Physical Therapy

Other

Current Medications & Dosage (if applicable)

Previous Experience with Occupational Therapy (if any):

Availability for OT Services:

Preferred Service Location

Clinic

Telehealth

Do you have an OT referral from your child's doctor?

Yes

Is there anything else you'd like to share before submitting your request?

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!