New Client Intake Form - Therapy 4 Kids
Thank you for your interest in Therapy 4 Kids.

Before we perform an evaluation or provide treatment you must fill out the information below. After we receive the below information our clinic will request a prescription from your child's doctor.

Medicaid - ARkids covers the cost of therapy. If you have another type of insurance you can check out our rates at Therapy4kids.net/rates. You will also find our privacy practices and notice there.

If you have any questions or concerns do not hesitate to call or text message us at 501-581-6045.

Email address *
Please fill out the information below
Child's Name *
Your answer
Child's Date of Birth *
MM
/
DD
/
YYYY
Parent / Legal Guardian Name *
Your answer
Parent / Legal guardian Phone Number *
Your answer
Parent / Legal Guardian Mailing Address *
Your answer
How did you hear about Therapy 4 Kids? *
Does child attend pre-school? If yes, which one?
Your answer
What days and times is your child at pre-school?
Your answer
Child's Doctor - Primary Care Physician
Your answer
Child's Insurance *
Required
Is your child currently receiving any of these *
Required
What type of therapy are you requesting *
Required
What are your concerns?
Your answer
Was your child born full term? *
Any complications during pregnancy? *
Your answer
What was your child's birth weight?
Your answer
Has your child ever been hospitalized? If so for what? *
Your answer
Has your child had tubes placed in ears? If so how many times and at what age?
Your answer
What medications is your child currently taking and for what?
Your answer
Any food or other allergies? Please list.
Your answer
Any history of seizures? If Yes, how many and when? *
Your answer
Any Allergies? If yes what? *
Your answer
Please type your name below giving us permission to evaluate and request paperwork for your child.
Your answer
The End - As soon as we get the prescription from the doctor we will perform the evaluation. If you already have a prescription let us know.
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