Client Intake Form
This form is to be completed by the parent/guardian of the client prior to the initial consultation visit
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Parent/Guardian Info
Information of the parent/guardian
Parent/Guardian 1 Name *
Parent/Guardian 1 Email *
Parent/Guardian 1 Phone *
Parent/Guardian 2 Name
Parent/Guardian 2 Email
Parent/Guardian 3 Phone
Primary Street Address *
Marital Status
Client's Information
Information of the person receiving services
Client's Full Name *
Date of Birth *
MM
/
DD
/
YYYY
Primary Street Address
Insurance Information
Provide Information for Insurance Carrier
Name of Insurance Company *
Name of Policy Holder *
Social Security Number of Policy Holder
Date of Birth of Policy Holder *
MM
/
DD
/
YYYY
Insurance Address *
Insurance Phone Number *
Member ID *
Group ID *
Medical Information
Name of Primary Care Physician
Physician Address
Physician Phone Number
Does the Client Have any Current Health Conditions
Clear selection
List medications and dosages that the client is currently taking
List all diagnoses
Diagnosing Physician
Date of Diagnosis
MM
/
DD
/
YYYY
Education Information
If the client is currently in school please complete the information below
Name of School
Classroom Type
Clear selection
Teacher's Name
Grade
Current/Previous Therapy Provider Information
Behavior Provider Name
Dates of Service
Therapy Outcomes
Speech Therapy Provider
Dates of Service
Therapy Outcomes
Clear selection
OT Therapy Provider
Dates of Service
Therapy Outcomes
Clear selection
Describe any problem behaviors
Provide any helpful information that may be helpful while assessing and or conducting therapy
How did you hear about us?
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This form was created inside of Optimal Outcomes, LLC.