childrenstheraplay_Patient_Group

New Patient Group Therapy Intake Form
Date

MonthDayYear
Date
How did you hear about groups at Children’s TherAplay?
Name of Person Completing this Form
Relationship to Child
Services Requested:
Patient Name
DOB

MonthDayYear
[Note: Child’s age must be between 5 years and 12 years 11 months old]
Sex Assigned at Birth:
Diagnosis
Preferred Language
All fields required -Please email us if you need assistance completing the following medical information:

Rows	Yes	No	Not sure
My child has an *aversion/fear* of animals (dogs/horses):
My child has a *severe allergy* to dogs/horses/hay:

A caregiver can attend and participate in sessions as required:
My child can eﬀectively communicate in a group setting:
Additional Comments:
My child can transition between activities every 5-15 minutes
Additional Comments:
My child requires 1:1 support to engage in therapy activities
Additional Comments:
My child gets overstimulated
Additional Comments:
My child eats food by mouth
Please note if your child has a g, ng, or nj tube:
Additional Comments:
My child can participate in group movement games, obstacle courses, or activities
Additional Comments:
My child has mobility aids:
Additional Comments:
My child demonstrates actions that could place the patient or others at significant safety risk (e.g., severely aggressive behaviors, frequent hitting, biting, throwing, scratching, screaming, or elopement)
Additional Comments:
My child has a medical condition with acute exacerbations (e.g., asthma flare ups, seizures, etc.)
Additional Comments:
Patient Name
DOB

MonthDayYear
Date
Caregivers/Guardian Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guardian 1 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Guardian 1 Email
example@example.com
Guardian 2 Phone
Please enter a valid phone number.Format: (000) 000-0000.
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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MD Phone
Please enter a valid phone number.Format: (000) 000-0000.
MD MD Fax
Please enter a valid phone number.Format: (000) 000-0000.
Therapies patient currently receives: (MUST COMPLETE-May impact insurance coverage)
Insurance
Please check ALL that apply
Type of MCD
Client’s 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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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.

Email this form to intake@childrenstheraplay.org
Should be Empty:

New Patient Group Therapy Intake Form

Insurance

Children’s Special Health Care Services (CSHCS)

Private Insurance