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New Patient Intake Form
Please complete this form as thoroughly as possible. Incomplete forms will delay processing of new intake.
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Child's Name
*
Your answer
Patient's Preferred Pronoun or nickname
Your answer
Which location do you prefer?
*
Farmington Hills
Troy
Required
Scheduling Availability (Day/Time)- Please note that some days/times may have a waitlist
*
Your answer
Name of Person Completing Form & Relationship to Child
*
Your answer
Child's Date of Birth
*
Your answer
Child's Age
*
Your answer
Child's Gender
*
Your answer
What is the primary language spoken at home?
*
English
Other:
Does Patient Live with Both Parents?
Yes
No
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How did you hear about The Therapy SPOT?
From a doctor or other professional
From a friend or family member
From the insurance company
From the internet
Other:
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