Intake procedure

After calling our office to schedule an evaluation, you will be directed to fill out and submit the following information to enter your child through our secure server. Thank you! We look forward to meeting you and your child!

Child's Name:*
First Last
Date of Birth:*
MM slash DD slash YYYY
Address:*
Street Address Address Line 2 City State ZIP Code
Phone:*
Referring Physician:*
Phone:
Other Physician(s):
If applicable, please list other Physicians and their phone numbers.
School:*
Grade:*
Teacher:*
Emergency Contact*
Phone:*
Parent(s)/Guardian(s):*
First Last
Is your address the same as the child's? Check 'Yes' below.
- Yes
Address
Street Address Address Line 2 City State ZIP Code
Home Number:
Cell Number:
Work Number:
Email:*
Preferred method of contact:*
Are your contact numbers & email the same as the child's? Check 'Yes' below.
- Yes
If they are different please fill in the Child's contact number(s) & email below.
Home Number:
Cell Number:
Work Number:
Email:*
Primary Insurance
Name of Insured:*
First Last
Date of Birth:*
MM slash DD slash YYYY
SSN:*
Employer:*
Employer Address:
Street Address Address Line 2 City State ZIP Code
Employer Phone:
Insurance Company:*
Group #:*
ID #:*
Insurance Co. Address:
Street Address Address Line 2 City State ZIP Code
Insurance Co. Phone:
Do you have Secondary Insurance?*
- Yes
- No
Secondary Insurance
Name of Insured:*
First Last
Date of Birth:*
MM slash DD slash YYYY
SSN:*
Employer:*
Employer Phone:
Employer Address:
Street Address Address Line 2 City State ZIP Code
Insurance Company:*
Group #:*
ID #:*
Insurance Co. Address:
Street Address Address Line 2 City State ZIP Code
We will do our best to determine your insurance benefits; however, it is your responsibility to know your insurance benefits, i.e., deductibles, co-pays, visit limitations, etc., and to be responsible for them. We are providers for most insurances but not all. You will be responsible to reimburse Hands On Therapy, Inc. the patient responsibility portion of your insurance plan if we are out of network.
Background Information
Birth History
- Full Term
- Premature
- Vaginal Delivery
- Caesarean
Please check all that apply.
*If you selected 'Premature' above, please tell us what week the baby was born in:
Any Complications?
Please explain, be as detailed as needed.
Medical History:
If there has been any Surgeries, Hospitalizations, Frequent Illnesses, Allergies & Current Medications please tell us about them in as much detail as needed.
Developmental Milestones
Please include year and/or month at which your child performed the following milestones. If your child has not performed a milestone, simply put N/A in the box.
At what age did the child begin rolling over:
At what age did the child begin sitting:
At what age did the child begin standing:
At what age did the child begin crawling:
At what age did the child say their first words:
At what age did the child begin riding a bike:
Please list the names of any siblings at home and their ages
Please describe your primary concerns related to your child’s development:
Please be as detailed as needed.
Signature*
Comments
This field is for validation purposes and should be left unchanged.

Background Information

Developmental Milestones

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Background Information

Developmental Milestones

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