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.
Please fill out the information below
Child's Date of Birth
Parent / Legal Guardian Name
Parent / Legal guardian Phone Number
Parent / Legal Guardian Mailing Address
How did you hear about Therapy 4 Kids?
Social Media - Facebook etc..
Sign on Building
Other Professional - Case Manager, Counselor, Teacher etc...
Child's Doctor - Primary Care Physician
Medicaid - AR Kids - TEFRA
PASSE (AR Total Care - Summit - Empower)
Is your child currently receiving any of these
Not Receiving Any Currently
What type of therapy are you requesting
Not sure which type they need
What are your concerns?
Was your child born full term?
No - They were more than 3 weeks early
Has your child ever been hospitalized? If so for what?
Has your child had tubes placed in ears? If so how many times and at what age?
Any food or other allergies? Please list.
Any history of seizures? If Yes, how many and when?
Where would you like therapy to happen?
My Child's Daycare
If you answered Daycare in question above, what is the name of the daycare?
Please type your name below giving us permission to evaluate and request paperwork for your child.
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.
Send me a copy of my responses.
Never submit passwords through Google Forms.
This form was created inside of Therapy 4 Kids.
Terms of Service