Schedule Your Child’s Evaluation Appointment

Please fill out the form below, and we will give you a call to schedule the appointment at a time that works for you. If you would prefer to give us all this information over the phone, feel free to call our clinics:

Wooster: 330-262-4449

Canal Fulton: 330-408-7575

Wooster Intake Form

What type of evaluation are you looking for?

Child's Name

First Name

Last Name

Age

Date of Birth

MM

DD

YYYY

Gender

Parent/Guardian Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Number

(###)

###

####

Phone

(###)

###

####

Email

Referred by

Insurance

Medical Diagnosis

If no diagnosis, please write "none"

Main concern

What are you seeing at home with your child?

Grade in school

School Attending

On IEP

Receiving OT/PT/SP currently? If yes, where?

How did you hear about us?

social media, referral, friend, online search, etc.

Checkbox

I am verifying this intake request is for the Wooster clinic

Yes

Canal Fulton Intake

What type of evaluation are you looking for?

Child's Name

First Name

Last Name

Age

Date of Birth

MM

DD

YYYY

Gender

Parent/Guardian Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Number

(###)

###

####

Phone

(###)

###

####

Email

Referred by

Insurance

Medical Diagnosis

If no diagnosis, please write "none"

Main concern

What are you seeing at home with your child?

Grade in school

School Attending

On IEP

Receiving OT/PT/SP currently? If yes, where?

How did you hear about us?

social media, referral, friend, online search, etc.

I am verifying that this intake request is for the Canal Fulton Clinic

Yes