childrenstheraplay

New Patient Intake Form
Date

MonthDayYear
Date
How did you hear about Childrens TherAplay?
Name of Person Completing this Form*
Relationship
Services Requested:*

Physical TherapyOccupational TherapySpeech Therapy
Patient Name*
DOB: *

MonthDayYear
NOTE: We accept ages 18 months – 12.5 years. For Down Syndrome, must be 2+ years.
Diagnosis*
Weight*
NOTE: We accept new clients up to 90 lbs. For children requiring full assistance, they must be less than 40 lbs.
Height
Sex Assigned at Birth:

MaleFemale
Preferred Language
Can your child sit independently?*

YesNo
Notes
Can your child walk independently?*

YesNo
Notes
Is your child verbal?*

YesNo
Notes
How much assistance/help is required for transfers?*

None25%50%75%100%
Notes
How long can your child hold their head up while in a seated position?*
Does your child have severe aversions/fears of animals (dogs/horses)?*

YesNoNot sure
Does your child have a severe allergy to dogs/horses/hay?*

YesNoNot sure
Does your child have any of the following health conditions?

Failure to report medical conditions may place your child at risk of injury. Please email us if you need assistance completing the following medical information:

	Yes	No
Atlanto-axial instability with neurological signsas assessed by MD
Mental health conditions that place the patient or others atsignificant safety risk (e.g., severely aggressive behaviors,frequent hitting, biting, throwing, scratching, screaming,or elopement)
Chiari malformation with neurologicalsymptoms (i.e., headaches, neck pain, balanceproblems, muscle weakness, numbness ortingling, visual disturbances, swallowingproblems, hearing loss and tinnitus, dizzinessand vertigo, sleep apnea, psychologicalconcerns such as insomnia or depression)
Coxa Arthrosis (a chronic disease that causes cartilage inthe hip joint to gradually deteriorate)
Seizures or unstable neurological systemuncontrolled (i.e., break through seizures) bymedication
Hemophilia with recent history of bleeding episodes
Indwelling urethral catheters
Medical conditions during acute exacerbations (e.g.,asthma flare ups, seizures, etc.)
Open wounds over a weightbearing surface
Pathological fractures without successful treatment of theunderlying pathology
Acute fractures
Tethered cord syndrome with or without symptoms (i.e.,pain in lower back, shooting leg paid, rectal and/or genitalpain, weakness or numbness in legs/feet, difficultystanding or walking or an abnormal walking pattern, lossof bladder or bowel control, urinary frequency, orconstipation, or worsening of scoliosis)
Unstable spine or joints and/or includingunstable internal hardware
Difficulties with being touched/handled during transfersor daily activities

Preferred Times for therapy appointments: (please check ALL options that apply)

Monday 8AMMonday 9AMMonday 10AMMonday 11AMMonday 12PMMonday 2:30PMMonday 3:30PMMonday 4:30PMMonday 5:30PM
Tuesday 8AMTuesday 9AMTuesday 10AMTuesday 11AMTuesday 1:30 PMTuesday 2:30PMTuesday 3:30PMTuesday 4:30PM
Wednesday 8AMWednesday 9AMWednesday 10AMWednesday 11AMWednesday 12PMWednesday 2:30PMWednesday 3:30PMWednesday 4:30PMWednesday 5:30PM
Thursday 8AMThursday 9AMThursday 10AMThursday 11AMThursday 1:30 PMThursday 2:30PMThursday 3:30PM
Friday 8AMFriday 9AMFriday 10AMFriday 11AMFriday 1 PMFriday 2 PMFriday 3 PMFriday 4 PM
Family Goals for Patient (write a couple sentences about your primary concerns/goals for therapy)*
Patient Name*
DOB

MonthDayYear
Date
Caregivers/Guardian Address*
City
State
Zip
Guardian 1 Phone*
Guardian 2 Phone
Guardian 1 Email*
example@example.com
Guardian 2 Email
example@example.com
Referring Physician Name (the physician who will be signing the referral for services and treatment notes)*
Physician's Medical Group Name
Physician's Address
City
State
Zip
MD Phone
MD Fax
Please enter a valid phone number.
Therapies patient currently receives:*

PTOTSTNone
Locations
Insurance: Please check ALL that apply*

MedicaidChildren’s Special Health Care ServicesSelf-PayPrivate InsuranceCareSource (Not In Network)
Type of MCD:

TraditionalWaiverRisk Based Managed Care
Clients RID #
Effective Date

MonthDayYear
Date
Children's Special Health Care Services (CSHCS):
ID #
Effective Date

MonthDayYear
Date
Private Insurance:
Private Insurance Company
Insurance Company Address
City
State
Zip
Insured's Name
DOB

MonthDayYear
Date
Relationship to Client
Policy/Group #
ID #
Member/Provider services phone number listed on back of card:
In Network Insurance Plans: Anthem, United Health Care, Cigna, Medicaid, Medicaid Entities (except Caresource). Out of network plans may have out of network benefits. Individual plans will vary, contact our billing department at billing@childrenstheraplay.org with any insurance questions.

Every family/patient must provide ALL current insurances. All changes in insurance must be provided. Failure to do SO will result in patient responsibility for the entire billable amount.
Should be Empty:

New Patient Intake Form