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Does your child need Speech and/or Occupational Therapy?
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Patient Intake Form
Child's Full Name
Child's Date of Birth
Insurance ID Number
Parent/Guardian's Name
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Does your child have Any Medical Conditions that they are being treated for by a physician (i.e. epilepsy)? Yes or No
Does your child attend Daycare/Preschool or Elemenatry School?
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Preschool or Elementary School Name. Please include the times your child attends
Does the child have an ASD diagnosis? If so, do you have the ASD report?
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Yes, and I have the ASD report.
Yes, but I do not have the ASD report.
Do you require Translation Services?
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I declare that the info I provided is accurate and complete.
Child's Health Insurance: Please include 2ndary if applicable
About
Meet Our Team
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Autism 101
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Intake Form
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