Intake Form Private/Group Therapy
Thank you for completing this information prior to evaluation and/or therapy sessions begin. Rainbow Tree Therapies, LLC is providing private therapy in one one one and small group sessions. Small group sessions occur when the fit is appropriate and there is a peer group to access. Animals may be used in therapy but consistently apart of therapy. There may be interactions with animals but we currently do not provide therapeutic horse riding as part of therapeutic services. Horse riding is consistently available during our Find Your Rhythm Camp during the Summer months and for occasional retreats offered in the Fall season.
Child's Date of Birth
Parent or Caregiver (s) Name
Parent/Caregiver Street Address
Parent/Caregiver Main Phone Contact Number
Emergency Contact Name and Number (can be the same as above)
What is Today's Date:
This form is for private or small group therapy. Please check that in which you are interested in receiving:
Private one on one therapy only.
Small Group Therapy only
Combination of both if possible.
Does your child have a diagnosis? If so, what is the diagnosis and who provided the diagnosis?
Significant Prenatal History:
Labor & Delivery (check any that apply)
Normal Vaginal Delivery
Full term 38 plus weeks
Baby Cried Immediately
Positive bonding with the parent
Premature more than 2 weeks.
Cord around the neck
Low Birth Weight
Baby was limp/floopy
Comments Regarding Labor & Delivery
Infancy & Toddlerhood
Disliked lying on stomach
Disliked lying on back
Calmed by car rides
Nauseated by car rides or infant swings
Difficult to comfort
Able to self soothe
Difficulty falling asleep
Irritated by Clothing tags or seams
Spit Up Frequently
Did/does not want to be held
Often needs parent to fall asleep
Dislikes certain food textures
Comments About Infancy & Toddlerhood
Age your child crawled?
Age your child walked?
Age your child spoke first word?
Is your child toilet trained
SCHOOL-AGE (Check all that apply)
Reported attention problems
Reported behavioral challenges related to defiance stubborn
Excels at academics - grade level
Receives Special Education for learning support
Melts down once home from school
Difficulty with transitioning to school
Has many friends
Has limited number of friends and a concern
Seems to enjoy school
Challenges with motor skills related to school function (dressing, writing, eating, playground)
Falls out of chair.
Awkward social skills
Limited diet- picky eater
Eats a variety of foods at school and home
Panic or anxiety attacks at school
Comments Regarding School Functioning
Please check all that applay to your child currently.
Chronic Ear Infections and/or Tubes
Wears hearing aids
Wears eye glasses
Allergies (seasonal or food)
Gastro-intestinal issues (constipation, diarrhea, bloating, frequent stomach aches)
Sleep Problems - difficulty falling asleep
Delayed Speech Development
Early Speech Development
Frequently covers ears at noises
Dislikes tags on clothing or complains of clothing not feeling right
Gets car sick frequently
Does not accept change in routine
Difficulty with transitions
Difficulty falling asleep
Impulsive or hyperactive
Difficulty with age appropriate self cares (dressing, feeding self, drinking from a cup, using utensils)
Runs away and hides frequently
Overly aggressive with toys or others
More meltdown than what would be typical given age
Appears Clumsy (trips, bumps into things, falls)
Can be hyper-focused to the point it interferes with social engagement
Can have difficulty coping with emotions
Has difficulty with friendships
Takes prescription medication
Family history of developmental concerns (Autism, Mental Illness, Learning Disability, ADHD, Anxiety)
Ever experienced physical, sexual, or emotional trauma either ongoing or in an acute incidence.
If you checked any of the above boxes, please include comments including medication name if prescribed and currently taking, how many meltdowns in a day and any additional comments regarding above.
Check what if any services your child currently receives or has received in the past.
Occupational Therapy - Private Clinic
Occupational Therapy - School Based
Please list your child's strengths and interests.
Please list your specific concerns regarding your child's development and challenges within the daily routine.
Please include any medical conditions that your child is managing or has in the past.
May we email you to communicate with you regarding your child?
Yes I give consent for electronic communication.
No I do NOT given consent for electronic communication.
Please check regarding Evaluation at Rainbow Tree Therapies, LLC
I will be providing a recent (within the past 8 months) Occupational Therapy evaluation. Please note it will need to be an evaluation and not progress note updates.
I do not have a recent evaluation and acknowledge that Rainbow Tree will complete an evaluation in the amount of $250.
Rainbow Tree is a cash based business model. Payment for the evaluation will be collected the day of the evaluation. If your child requires direct therapy services, an invoice will be sent to you for an up front payment of 4 sessions. This payment will be made prior to any services provided. It is likely that your child may require at least 12 total sessions. Fee per session is $80. After 4 sessions, you and your providing therapist can discuss continued need or plan for therapy.
I agree to pay upfront for at minimum of 4 therapy sessions and understand this is required for services to be provided.
I understand that insurance will not be billed and the expectation is cash payment.
I understand that if using a credit card or Health Savings Account card, there is a small fee attached to the service fee. The fee is typically 1-3%
Superbill - A superbill is a document provided after payment that could be submitted to insurance for POSSIBLE reimbursement. You are responsible for submitting to insurance.
Yes I would like a superbill.
No I do not require a superbill.
By checking each of the the following, you are agreeing with the statements in their totality.
I recognize that my child may be engaging in therapy outdoors and indoors at Rainbow Tree and agree to dress them for the weather. .
I confirm that I am responsible for any bug spray or sunscreen that I would want my child to be wearing prior to treatment or evaluation sessions.
I agree to do my best to meet all scheduled appointments with Rainbow Tree. I will review cancellation policy on the website under "Private Therapy Options & FAQ's section"
I understand that Rainbow Tree uses a wide range of treatment strategies and some may be defined as complimentary such as mindfulness, meditation, visualization and energy work.
I consent to agree to email communication with those professionals working at Rainbow Tree Therapies, LLC
RELEASE/HOLD HARMLESS/AUTHORIZATION OF MEDICAL TREATMENT
The following will seek your permission for release of information and for permission for Occupational Therapy graduate students to observe and/or be apart of therapy.
I authorize the therapists at Rainbow Tree Therapies LLC to allow my child to occasionally be observed during therapy sessions by fieldwork students/interns and/or volunteers. I understand that these individuals will be signing confidentiality agreements. This agreement remains in affect until your child has been officially discharged from therapy.
YES I authorize
NO I do not authorize observation.
I agree to the above. Add Your Name & Date you agreed.
Release of Information (read below)
Information to be released would include evaluation information and goals.
I authorize Rainbow Tree Therapies to release information to, obtain information from and exchange information with the following listed private therapy clinic, school personnel, or physician that you would like us to consult with to provide comprehensive or collaborative support regarding your child. ****By listing the names and contact number, you are authorizing this release. If not authorizing anyone, please indicate "NO AUTHORIZATION." This authorization will be in affect until your child has been discharged from therapy at Rainbow Tree Therapies and updated as needed.
I agree to the above and I understand that I have the right to refuse to sign this form and I may revoke my consent in writing at any time (except to the extent that the information has already been released). Add your Name & Date you agreed.
Release Of Liability/Hold Harmless/Photo Release/Medical Authorization. PLEASE CHECK ALL THAT MAY APPLY.
I have READ the Release of Liability and Consent page: Link to it here:
I agree to the Release of Liability agreements for ALL services at Rainbow Tree including interactions with animals if applicable.
I GIVE consent for photos to be taken during group therapy. Photos will not be taken during private therapy sessions
I DO NOT agree. I prefer NO photos taken of my child.
I authorize emergency medical treatment.
I do NOT authorize emergency medical treatment & will agree to provide a preferred plan of care to Rainbow Tree.
Provide your Name & Date to which you agreed to above.
CONTACT INFORMATION FOR RAINBOW TREE:
Rainbow Tree Therapies, LLC
477 Perch Lake Rd
Hudson, WI 54016
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