JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Patient intake form
Please complete all information to expedite intake process thank you!
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Mother Parent/Guardians name (first name, last name)
*
Your answer
Father Parent/Guardians name (first name, last name)
Your answer
Patient/child name (first name, last name)
*
Your answer
Date of birth
*
MM
/
DD
/
YYYY
Phone number (personal)
*
Your answer
Phone number (business)
Your answer
Email
*
Your answer
Address
*
Your answer
Marital status
*
Married
Single
Separated
Divorced
Other:
Parent/Guardian(s) with custody of child
*
Your answer
Attend School?
*
Yes
No
Other:
Name of school (N/A if not in school)
*
Your answer
Grade
Your answer
Date enrolled
MM
/
DD
/
YYYY
Date of recent IEP
MM
/
DD
/
YYYY
Placement in school (N/A if not in school)
*
Inclusion/Gen ed
Special Ed
SLC/life skills
Non-public school/home school
Other:
Related Services
Current and past services (check all that apply)
*
Speech
OT/occupational therapy
Physical Therapy
ABA Therapy
none
Other:
Required
Please provide agency information for above services (provider name,dates of services, Address /phone number
Your answer
Can we contact above providers?
*
Yes
No
Other:
Required
Who is the referring physician? (first name, last name)
*
Your answer
Referring Physician address (address, city, St, Zip code)
*
Your answer
Referring Physician phone number
*
Your answer
Did referring physician make diagnosis?
*
Yes
No
Other:
if no please enter diagnosing physician
Your answer
Primary Physician name
Your answer
Primary Physician phone
Your answer
Insurance Information
Insurance name
*
Your answer
Client/patient SSN
*
Your answer
Member ID
*
Your answer
Group ID
*
Your answer
Client/patient relationship to policy holder
*
Mother
Father
Guardian
Is Policy holder
Other:
Policy Holder Name(first name, last name)
*
Your answer
Policy Holder DOB
*
MM
/
DD
/
YYYY
Policy Holder Employer
*
Your answer
Employer address
Your answer
Medical History
When was your Child's last Dr. Visit?
*
MM
/
DD
/
YYYY
Is Your child currently taking any medication?
*
Yes
No
Other:
Please list all medications and administration times
Your answer
Primary diagnosis
*
Autism
Intellectual Disability
Down's Syndrome
ADHD
Other:
Secondary Diagnosis
Autism
Intellectual Disability
Down's Syndrome
ADHD
Other:
Clear selection
Allergies?
*
Your answer
Medical Conditions?
*
Your answer
Special Diets?
*
Your answer
What age did you suspect problem with your child's development?
*
Your answer
Has your child exhibited any loss of skills in any area?
*
Yes
No
Other:
If yes please explain
Your answer
Please list Household members/Siblings who live in the home
*
Your answer
Social & Play Skills
Does your child play independently?
Yes
No
Other:
Clear selection
Does you child play with toys appropriately?
*
Yes
No
Other:
Does you child attempt to play with others?
*
Yes
No
Other:
Does you child engage in interactive play with other children? (hide and seek, tag, etc)
*
Yes
No
Other:
Does your child engage in pretend play? (dress up, house, pretend to be cartoon character etc)
*
Yes
No
Other:
Communication skills
Please answer question regarding your child's communication skills.
Does you child communicate verbally?
*
Yes
No
Other:
Does you child respond when his/her name is called?
*
Yes
No
Other:
Does you child imitate sounds?
*
Yes
No
Other:
Does you child follow simple instructions?
*
Yes
No
Other:
Does you child make eye contact?
*
Yes
No
Other:
Does you child label items/events/actions? (see dog then say dog, see jumping the says jumping etc)
*
Yes
No
Other:
Does your child answer "WH" questions? (who,,what, when, where)
*
Yes
No
Other:
Does your child have conversations with others?
*
Yes
No
Other:
Describe how your child communicates what he/she wants?
*
Your answer
Academic skills
Please answer questions regarding your child's academic skills
Can your child perform any of the following? (check all that apply)
*
Identify numbers
Identify letters
Complete puzzle
Match items
Sort colors/shapes
Stack blocks
Draw
Write letters
Write numbers
Identifies people
Other:
Required
Motor skills
Can your child imitate simple gestures? (waving, clapping)
*
Yes
No
Other:
Can your child imitate simple gestures using objects? (banging a drum, shaking a noise making toy)
*
Yes
No
Other:
Can your child imitate fine motor gesture? (snapping a button together, picking up a small item with in between 2 fingers)
*
Yes
No
Other:
Describe your child's fine motor skills (buttoning clothes, turning pages, cutting with scissors etc)
*
Your answer
Describe your child's fine motor skills (buttoning clothes, turning pages, cutting with scissors etc)
*
Your answer
Describe your child's gross motor skills (catching a ball, jumping, climbing etc)
*
Your answer
Self Help Skills
Can your child independently perform any of these self help skills? (check all that apply)
*
Potty trained
Feed Self
Dress Self
Clean up after self
Required
Behaviors of Concern
Does your child engage in any of these behaviors? (check all that apply)
*
Physical aggression toward others
Physical aggression toward self
Unsafe behaviors (climbing, wandering off, touching items)
Property destruction (throwing items, breaking items, kicking objects)
Engage in ritualistic behaviors/obsessive behaviors (wearing same clothing, same topic of conversations, making noises)
Drop to the ground spontaneously
Inappropriate sexual behaviors
Eat items that are inedible
Non-compliance
Verbal agression
Required
Please list any additional behavior concerns (please include frequency per day, how long it lasts, and if it is severe, moderate, or mild in intensity)
*
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
