STN New Client Intake Form
Please complete a new client intake form to be placed on our waitlist for services. We will follow up with you via phone and email to ensure that we received your request and outline next steps for an evaluation and therapy.

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Email *
What services are you interested in? (please select all that apply) *
Required
Patient First & Last Name *
Patient Birthdate *
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Patient Pronouns:
Have you been in services with Seattle Therapy Network before? *
Is this intake in response to receiving results regarding a developmental screening at your child's school/daycare by an STN SLP/OT?
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Name of patient's school or patient's employer: 
Please list any known diagnoses:  
Please describe your concerns and priorities for seeking therapy: *
Primary Contact: First & Last Name and Pronouns *
Primary Contact: Phone number *
Primary Contact: Email *
Primary Care Provider (Please include both provider's name and clinic) *
Primary Insurance: *
Primary Insurance ID *
Do you have secondary insurance? If so, please include the provider name and insurance ID number below.
**By completing this intake the primary contact agrees to electronic communications for intake, scheduling, and updates. We will never share your information with outside marketing businesses. If you do not consent to electronic communications, please call our office at 206-763-0352
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A copy of your responses will be emailed to the address you provided.
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