Occupational Therapy Client Intake Form

Child's First Name*

Child's Last Name*

Child's Date of Birth*

Parents First Name*

Parents Last Name*

Address*

City*

State*

Zip*

Phone*

Email*

How did you hear about us?*

Insurance Carrier*

Insurance ID*

Insurance Group*

Pediatrician's name

OT Concerns*

Pre-natal History*

Medical History*

Developmental History*

Goals for Therapy*

Do you authorize OT Studios to use photos or videos of your child during OT sessions for education purposes on our website/social media?*
YesNo

*The above information is true and complete to the best of my knowledge. I am aware of the evaluation and treatment protocols of Occupational Therapy and I authorize OT Studios, Inc and its clinicians to evaluate, assess and provide treatment to my child.

First Name*

Last Name*

Date*

Signature*

Use your mouse or finger to draw your signature above