Ready to slide into our calendar? Let’s Connect. To expedite our process, fill out the form below, and I will be in touch with you soon. For general inquiries, email: hello@innovativetherapyapex.comI look forward to connecting! Open Form Client Intake Parent Name * First Name Last Name Client Name: Address: Address 1 Address 2 City State/Province Zip/Postal Code Country Phone: * (###) ### #### Email: * Are you interested in: Therapy Evaluation Social Skills Group Client Date of Birth: Insurance: Referred by: Physician: Presenting Concerns: Child's Strengths: Complications during pregnancy? Y/N Complications during delivery? Y/N Has your child ever been seen by any of the following? Neurologist Psychologist Psychiatrist If yes, please explain. Has your child had any of the following: Highlight any that apply. Ear Infections Autism Chronic Colds Feeding Concerns Ear Tubes ADD/ADHD LD Allergies Other? Additional information on applicable items, if necessary: THERAPY HISTORY Is your child receiving or received in the past: Speech/language therapy Occupational Physical Where/When/Why Please explain the circumstances of these types of therapy. Concerns about play/interaction skills? Y/N Concerns about behavior? Check all that apply. Difficult to soothe/calm Has strategies to self-calm Irritable Prone to rapid/extreme mood shifts Impulsive Pinch self or others Bite self or others Otherwise hurt self or others Significant changes in the family? (Severe illness, deaths, moves, divorce, etc.) Have any of the above affected your family dynamic? Please explain. Any other information that might be helpful in understanding your child? INSURANCE COMPANY AND MEMBER ID # NAME OF PRIMARY INSURANCE HOLDER PRIMARY INSURANCE HOLDER’S BIRTHDATE Thank you!You will receive a follow-up within 3-5 business days.
