Judith A Simmons OTR/L Patient Intake Form  
This is a brief form that helps me identify basic information about you and your family's needs. Please answer honestly and with as much detail as you feel is necessary. I will be sure to respond shortly after this form has been submitted. Thanks!
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Office Information
4608 224th Ct NE Redmond, WA 98053
Phone: 425-868-7968
Fax: 425-868-5192
jasimm@comcast.net
Child's Name (first no body and last): *
Sex of Child: *
Parent Name #1 *
Parent Name #2 (if applicable)
Best email to reach you at: *
Best Phone number to reach you at: *
Child's Date of Birth: *
What is the best time to reach you? *
Employer [of insurance policy owner] *
Primary Insurance Provider *
(i.e. aetna, etc...)
Primary Subscriber Name *
Subscriber Date of Birth *
MM
/
DD
/
YYYY
Insurance ID #: (Please include alpha/numeric) *
Does either parent carry any other insurance on this child?
Clear selection
Does your insurance require a referral or pre-authorization? *
Insurance Customer support number (usually on the back of the insurance card): *
Briefly describe the issues your child is experiencing: *
Who recommended my services? *
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