Join the Arrowleaf Developmental Pediatrics Patient List

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Thank you for contacting Arrowleaf Developmental Pediatrics! At this time we are seeing children 10 years and younger. Please complete this brief intake questionnaire to request your child's Developmental Pediatrics or Therapy Appointment.

Name of Parent/Guardian/Caregiver? *

Email Address: *

Child's name? *

What is your child's gender? *

Female

Male

Prefer not to answer

Other:

Home address? *

Phone number? *

Child's Date of Birth? *

YYYY

Health Insurance? *

Blue Cross of Idaho

Regence BlueShield Idaho

Blue Cross Blue Shield Federal Employee Program

St. Alphonsus Health Alliance

St. Luke's Health Plan

First Choice Health Plan

Moda Health

Mountain Health Co-op

PacificSource Health Plans

Select Health

Other:

Are you a previous patient of Dr. Amy Francis, Monica McCullough, Dawn Orchard, Kendra Lindeman, or Sami Ruggles? *

Yes

If yes, which provider did your child see?

Dr. Amy Francis

Monica McCullough

Dawn Orchard

Kendra Lindeman

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What developmental questions do you have about your child? Check all that apply. *

Speech language delay

Gross motor delay (e.g., not walking)

Fine motor delay

Decreased eye contact

Sensory seeking or sensory avoidant behavior

Behavior/tantrums

Inattention

Hyperactivity

Learning Difficulties

Other:

Required

Please list any medical or developmental diagnoses that your child has? Check all that apply. *

Developmental Delay

Speech Delay

Sensory Processing Disorder

Autism

Attention Deficit Hyperactivity Disorder

Learning Disability

Cerebral Palsy

Genetic Syndrome

Other:

Required

What therapies does your child receive or did receive in the past? Check all that apply. *

Speech Therapy

Occupational Therapy

Physical Therapy

Developmental Therapy

Feeding Therapy

Behavior Therapy

My child does not receive therapy.

Other:

Required

How can we help? *

Developmental Pediatrician Visit

Autism Evaluation

Occupational Therapy

Speech Language Therapy

Other:

Required

Thank you for completing this questionnaire! You will be contacted by text or email soon about joining the patient portal and scheduling your child's appointment.

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