Intake Forms

Downloadable forms are available in your choide of Adobe PDF or Microsoft Word format. You can:

Download and print Adobe PDF forms, fill them out and bring them to your first appointment or fax to 954.680.8974.

Open Microsoft Word forms, fill them out, save document, and return as an email attachment

Please note that all information provided on these forms is confidential. If you have any questions, please contact us by phone or email. Thank you for your cooperation.

Intake Form	Intake Form
Insurance Form	Insurance Form

Click on image to download forms.
PDF may be printed and filled out by hand; Word version may be opened in Microsoft Word with answers typed in.

Initial Intake Form

Therapeutic Connections - Pediatric Speech and Occupational Therapy - Your Therapy Team

The purpose of the Initial Intake Form is to provide Therapeutic Connections with the all information we need to evaluate your child so we may design an inclusive treatment plan based on your child's individual needs. We require information in the following areas:

Patient Information

Background information

Prenatal / Birth History

Developmental History

Speech - Language Developmental

Medical History

Educational Background

Functional Status

Sensorimotor History
The form also covers the Attendance Policy and Payment Policy
for Therapeutic Connections.

Therapeutic Connections - Pediatric Speech and Occupational Therapy - Your Therapy Team

Intake Insurance Form

The Intake Insurance Form is used only for the purposes of Therapeutic Connections insurance and payment obligations. We require information in the following areas:

Patient Information

Parent / Guardian Information

Diagnosis Information

Insurance Information
The form also includes an Assignment and Release which must be signed for evaluation and therapy to begin.