Excel Care Pediatric Intake Form

Thank you for contacting Excel Care Therapy.

Please fill out the enclosed form in order for us to schedule the initial evaluation with one of our licensed therapists.  One of our team members will contact you within 1 business day to get more details and set up an appointment.

If you wish, you can contact us via phone at 602-903-4072, or email us at info@excelcaretherapy.com.

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Patient's Full Name (First Name Last Name) *
Gender *
Current age *
Date of Birth *
MM
/
DD
/
YYYY
Address *
Mother's name *
Mother's email *
Father's name
Father's email
Primary cell phone *
Child's School name *
Who referred you?
What type of classroom? (e.g, regular education, integrated, substantially separate)  *
Describe your current concerns: *
What subjects are difficult for your child? *
Primary Care Physician: 
Name of Primary Doctor *
Name of Practice *
Physician's address *
Physician's Phone Number
Child's medications *
Child's Allergies *
Medial Diagnosis *
Hearing & Vision
History of ear infections? if so explain on when and treatments *
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