Wooster Clinic Online Intake FormsBelow are the online intake forms for the WOOSTER CLINIC.Please be sure to fill out all 3 forms. New Patient Information Form Date * MM DD YYYY Child's Name * First Name Last Name Date of Birth * MM DD YYYY Age * Sex * Male Female Child's Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Parents/Guardian Name * First Name Last Name Parent/Guardian Address Only fill out if parent/guardian address is different than child's Address 1 Address 2 City State/Province Zip/Postal Code Country Cell Number * (###) ### #### Home Phone (###) ### #### Email Address * Referring Physician/Pediatrician Physician Phone Number (###) ### #### Medical Diagnosis Insurance company (primary) * Policy Holder's Name * First Name Last Name Policy Holder Date of Birth * MM DD YYYY Insured ID # * Group # If unknown add 1111 Policy # If unknown add 1111 Coverage-How many visits will insurance cover for your child to receive per year? Deductible Amount Co-pay Does your plan require pre-authorization for OT/PT/SP visits? Yes No Is child covered under another insurance policy? * Yes No If so, please provide secondary insurance information here Thank you! PLEASE BRING YOUR INSURANCE CARD TO THE FIRST VISIT New Patient Medical Information Child's Name * First Name Last Name Date of Birth * MM DD YYYY Was your child born full term or premature? * full term premature If your child was born premature, how many weeks? Was your child placed in NICU following birth? If so, for what reason(s) and how long? * Are your child's immunizations up to date? * Yes No Has your child's developmental milestones been met? If no, please explain: * List allergies: * Current medications: * Does your child use special equipment (ex. Braces, splints, adaptive utensils)? * Has your child received occupational/physical/speech therapy before? If so, which one and for how long? * Date of last evaluation (if this is not applicable to your child, please put N/A) * What are your main concerns with you child? * Is there anything else our therapists should know regarding your child that may assist us in working with them? (i.e. other concern, autism, behaviors, etc.) * Who lives in the home? * What are your child's strengths? * What are your child's interests? * Has your child experienced any major life events? (i.e. grief, divorce, etc.) If yes, please explain: * Thank you! Emergency Contact/Allergies Form Parent's Name * First Name Last Name Child's Name * First Name Last Name Emergency Phone Number * (###) ### #### Allergies * Other Information * Thank you! There are other forms that require signatures that will be filled out at the first visit. Please take a look at them here:Privacy Notice Release of Information and Photo Release FormTherapy Policies and Consent
