We are so happy that you have chosen us to be a part of your child’s journey to grow and develop!

In order for us to get started with the speech and language or occupational therapy process (evaluation and treatment), we require the following information and paperwork to be completed and submitted to us.

A copy of the child’s insurance card (front and back).
The following forms listed are to be filled out electronically and submitted for our records:

Client Intake Form
Consent to Treat in Daycare (if applicable)
Signature Authorization Page
Authorization to Release and Receive Information
Developmental/Medical History

Completely read and keep the following forms for your records

Para descargar el formulario de la versión en español, haga clic aquí.

We look forward to working with your child and your family!

If you have any questions, concerns, comments please call (919) 359-1323 or email us at info@NowWereTalkingPT.com

CLIENT INTAKE FORM

Telephone: (919) 359-1323
Price range: $$

This form provides your demographics for office keeping.

Child's Name(Required)

First Last

Date(Required)

Please, tell us why you're here...(Required)

You may select as many as you need to.

Speech Therapy

Occupational Therapy

Physical Therapy

Address(Required)

Street Address Address Line 2 City State ZIP Code

Date of Birth(Required)

Sex(Required)

Parent/Guardian Name(Required)

First Last

Parent/Guardian Phone(Required)

Cell Phone(Required)

Work Phone

Email(Required)

Enter Email Confirm Email

Add a Parent or Guardian?(Required)

Yes

No

Parent/Guardian Name(Required)

First Last

Parent/Guardian Phone(Required)

Cell Phone(Required)

Work Phone

Email(Required)

Enter Email Confirm Email

Pediatrician Practice(Required)

Pediatrician Office Phone Number

Office Fax

Primary Diagnosis / Medical Concern(Required)

Primary Insurance Company(Required)

Plan

Subscriber Number(Required)

2 Digit Number Next to Patients Name

Please enter a number from 00 to 99.

Do You Have Secondary Insurance(Required)

Yes

No

How would you like your invoice sent to you?(Required)

E-mailed

Mailed

N/A

Secondary Insurance Company(Required)

Secondary Plan

Secondary Plan Subscriber Number(Required)

Secondary Plans 2 Digit Number Next to Patients Name

Please enter a number from 00 to 99.

Place of Therapy(Required)

Please choose one

Additional Details?

If you have any additional comments on therapy location please add them below.

Medical Records

Date(Required)

Person Completing Form(Required)

Child's Name(Required)

First Last

Date of Birth(Required)

Age(Required)

Sex(Required)

Parent/Guardian:(Required)

Reason for Referral(Required)

Others Living in the House

Relationship

Age

History of Delays

Others Living in the House 1

Relationship 1

Age 1

History of Delays 1

Others Living in the House 2

Relationship 2

Age 2

History of Delays 2

Others Living in the House 3

Relationship 3

Age 3

History of Delays 3

Others Living in the House 4

Relationship 4

Age 4

History of Delays 4

Prenatal and Birth History

Please describe the mother's general health during the pregnancy of this child (illnesses, accidents, medications, complications, etc.)

Length of pregnancy?(Required)

Term(Required)

Full Term

Premature

Describe any unusual conditions at or immediately after birth

APGAR Score

Birth Weight

Hospital Stay

How Long?

Additional History and Background

Primary Language Spoken at Home(Required)

Please list all the languages your child can speak and understand.

With whom does your child spend most of their time?(Required)

Does your child CURRENTLY receive any of the following services?(Required)

Early Intervention

Occupational Therapy

Speech-Language

Public School Services

Physical Therapy

Visual Impaired Services

None

Please indicate where and within whom...(Required)

Have any other specialists seen your child in the PAST?(Required)

e.g., speech-language pathologist, occupations therapist, physical therapist, physicians, psychologists, special education teachers, etc...?

Please describe your concerns and what your goals for your child are(Required)

Forms

Fill Out Your Paperwork Here

Now We're Talking Intake Forms

CLIENT INTAKE FORM

Medical Records

Prenatal and Birth History

Medical History

DEVELOPMENTAL/MEDICAL HISTORY

Developmental History

Additional History and Background

Consent and Authorizations

CONSENT TO TREAT IN DAYCARE/PRESCHOOL FACILITY

COVID-19 POLICY

IF ANYONE IN YOUR FAMILY IS SICK, HAS BEEN EXPOSED TO OTHERS WHO ARE SICK OR HAVE RECENTLY TRAVELED TO A COVID-19 HOTSPOT, PLEASE CANCEL AND RESCHEDULE YOUR THERAPY APPOINTMENT

AUTHORIZATION PAGE

AUTHORIZATION OF RELEASE/RECEIPT OF PATIENT INFORMATION