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Virtual Clinic Intake Form
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* Indicates required question
Please read and agree to the terms and conditions below
*
I agree to the terms and conditions of the Telepractice Consent Form
Required
Child's First Name
*
Your answer
Child's Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Parent/Guardian Name
*
Your answer
Street Address
Your answer
City, State, Zip
Your answer
Preferred Phone #
Your answer
Email Address
Your answer
What services are you interested in for your child?
Speech/Language Therapy
Occupational Therapy
Does your child currently receive therapy services or have they in the past?
Yes
No
Clear selection
Enter the name of your child's current therapist, if known.
Your answer
Has your child completed a therapy evaluation within the last year?
Yes
No
Clear selection
Please email a copy of your child's evaluation to
VirtualClinic@stellartherapy.com
.
I will email my child's evaluation
My child needs an evaluation
Clear selection
If you are unable to provide a current evaluation for your child, a new one will need to be performed by our therapist. The charge for a new evaluation is $150.00.
I understand
Why are you seeking therapy for your child?
Your answer
Please tell us any specific concerns you have.
Your answer
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