Therapeutic Connections
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Intake Forms
Downloadable forms are available in your choice 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.
Intake Form Intake PDF Intake Form Intake Doc Insurance Form Insurance PDF Insurance Form Insurance Doc
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Please note that all information provided on these forms is confidential.
If you have any questions, please contact us by phone or email.

Initial Intake Form

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. 		Social Skills Training

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
  • Insurance Information
 Communication Enhancement & Development
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