CLIENT INTAKE FORM

EMERGENCY MEMO:
IN THE UNLIKELY EVENT OF AN EMERGENCY DURING A SESSION, PLEASE ENSURE YOUR THERAPIST HAS A WAY TO REACH YOU (CELL PHONE ETC.)

Child's Name

First Name

Last Name

DOB

MM

DD

YYYY

Sex

MALE

FEMALE

School

Grade

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Email

Mother's Name

First Name

Last Name

Mother's Email

Mother's Employer

Mother's Cell

(###)

###

####

Mother's Work

(###)

###

####

Father's Name

Father's Email

Father's Employer

Father's Cell

(###)

###

####

Father's Work

(###)

###

####

Guardian

First Name

Last Name

Guardian's Email

Guardian's Phone

(###)

###

####

PERMISSION TO LEAVE MESSAGE ON ANSWERING MACHINE

YES

NO

NAME AND RELATIONSHIP OF INDIVIDUAL WHO MAY ACCOMPANY YOUR CHILD TO THERAPY IF NOT A PARENT:

REFERRING PHYSICIAN

PHONE

(###)

###

####

ADDRESS

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

PRIMARY CARE PEDIATRICIAN

PHONE

(###)

###

####

ADDRESS

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

DIAGNOSIS: PRIMARY:

SECONDARY:

WHO REFERRED YOU TO US?

REASON FOR REFERRAL:

SIBLINGS

Please list their names and DOB

MEDICAL HISTORY INFORMATION

RESEARCH, EDUCATION, AND MEDIA

I allow and consent for therapy students (physical, occupational and speech) and visiting therapists to observe my child’s therapy.

I allow and consent for photos/videos to be taken of my child for educational purposes at The Village Therapy Place. I understand that I can access all recordings and photographs prior to publication.

I allow and consent for photos/videos to be taken of my child for use in educational workshops presented by The Village Therapy Place and The Village Therapy Place website and social media.

RELEASE FORM

I allow and consent for The Village Therapy Place to send me information about my child through the following modes of communication: (Please post your intials

If you would like The Village Therapy Place to communicate with any physicians, therapists, teachers and any other professional who works with your child, whether initiated by The Village Therapy Place or other provider, please indicate below.