EmailMe Form - Patient Intake Form- Creative Therapy Works, LLC

Patient's Name

First Middle Last

(as it appears on the insurance card)

Cell Phone

### - ### - ####

Home Phone

### - ### - ####

Can we text information regarding your appointments to your cell phone?

Yes

No

If yes to texting, please list your cell phone's carrier (i.e. Sprint, Verizon, etc)

Email

Confirm

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Patient's Age:

Patient's Gender

Primary Care Physician/ Pediatric Office Name

Patient's Insurance Provider:

Blue Cross Blue Shield- PPO

Federal Blue Cross Blue Shield

Blue Cross Blue Shield- HMO

Medicaid (SSI)

Peach State (Medicaid)

Amerigroup (Medicaid)

Other with Katie Beckett Waiver

Other (out of network)

Self Pay

If your insurance is not listed we do not currently accept it. Please notify us so we can talk about "Self Pay" options.

Insurance Subscriber Identification Number

Family Information

Please Answer the Following Questions about Child's Home Dynamics:

Parent 1 Name

First Last

Parent 1 Age

Parent 2 Name

First Last

Parent 2 Age

Does your child have siblings?

Yes

No

Sibling Names and Ages:

Check any that apply to concerns you have related to the scheduled appointment:

Patient Not Talking (babbles/ jargon limited words)

Loss of Language (had language and now it appears to regressing)

Articulation- Can't understand what patient is saying

Patient has difficulty Expressing Self

Stuttering (Repeating sounds and words)

Difficult with Reading/ Spelling

Delayed Milestones- (motor, self care, writing)

Poor Emotional Control (upsets real easily)

Stroke/ Brain Injury

Comments, Additional Reason(s) for Scheduled Appointment:

Be as specific about why you made this evaluation appointment so that we can ensure we select the most appropriate assessment(s) for your child's evaluation

Have any other immediate family (parents, siblings, grandparents) had any of the above deficits at any time?

Check how much YOU understand of child's speech at this time

75-100%

50-75%

25-50%

none

Check how much OTHERS understand of child's speech at this time

75-100%

50-75%

25-50%

none

Please put a check next to what your child currently does to communicate with you?

Please list any other professionals that have worked with or evaluated your child? ( psychologist, Babies Can't Wait, Marcus Center, other therapy center etc.)

Please put N/A if not applicable

Please indicate if your child has an IFSP (Infant Family Service Plan with Babies Can't Wait) or an IEP (Individulalized Education Plan). Yes or No and last date it was done.

Please put N/A if not applicable

Please indicate any diagnosis that you child has been diagnosed with if any. (exp. Autism, Dyslexia, ADHD etc.)

Please put N/A if not applicable

Please indicate any complications at birth or problems during pregnancy that may have occurred.

Please put N/A if not applicable

Please list anything that your child enjoys (i.e. toys, characters, activities)

Please list your child's strengths (exp. friendly, good listener, happy, math)

Please list any medications that your child is currently taking right now.

Has your child ever had a speech/ language evaluation?

Yes

No

Has your child ever had a speech/ language therapy?

Yes

No

When/ Where was the last Speech Therapy session done?

Please put N/A if not applicable

When was the Speech Evaluation done?

Please put N/A if not applicable

Has your child ever had Occupational Therapy?

Yes

No

Has your child ever had an Occupational Therapy Evaluation?

Yes

No

When/ Where was the last OT session done?

Please put N/A if not applicable

When and Where was the last Occupational Therapy Evaluation done?

Please put N/A if not applicable

Do you currently have concerns about Autism in your child?

Yes

No

Is your child enrolled in school or preschool?

Yes

No

Type of School Currently Attending

Name of School

Any additional comments, questions, or concerns:

Who can we thank for referring you to Creative Therapy Works?

I give permission for the content of this patient intake form to be shared with my insurance company and primary/ referring physician in the context of patient care and development of an evaluation and plan of care.
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