OT Child Intake

Parent or Guardian Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Parent or Guardian Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
INSURANCE INFORMATION

We are in-network with BCBS PPO and Macomb County Community Mental Health. We are also a certified non-network provider for Tricare.

As a curtesy, we will submit billing to out-of-network PPO plans but payment is due at the time of service.

We cannot bill to HMO plans or Medicaid plans. Please contact the office for cash prices.
Primary Insurance*

Insurance Provider

Subscriber Name and DOB

Policy NumberGroup Number

Phone Number
Secondary Insurance

Insurance Provider

Subscriber Name and DOB

Policy NumberGroup Number

Phone Number
Is your child in Physical Therapy, Speech Therapy, or do they see a Chiropractor?
Upload a photo of the Front and Back of your insurance card.

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Physician's Information

Physician's Name

Office or Clinic Name

Phone NumberState / Province

Postal / Zip Code
Do you have a prescription for occupational therapy?*
Upload your prescription here.

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Please describe what your current concerns for you child are at this time.*
ex: academics, ADLs, relationships, sensory, speech, gross or fine motor, play, feeding, etc.
How can we be most helpful to you and your child?*
Do you have any concerns with self-care (bathing, eating, dressing, grooming)?*
Do you have any concerns with coordination ( gross and fine motor)?*
Is you child flexible with change? Please describe. *
What do you hope to achieve with therapy at Flourishing Lives?*
How long can your child sit at a table and pay attention to a non-preferred task.*

Less than 1 minute1 to 5 minutes5 to 15 minutes15 to 30 minutes30 minutes or more
Please describe your child's relationships and play with others. *
What does your child like to play or do in their free time?*
My child can consistently follow multi-step verbal directions.*

unable to follow verbal directions1 step at a time2 steps at a timemore than 2 steps at a time
Are there any precautions we should be aware of?*
ex. allergies, elopement, triggers, aggression, etc.
Do you have anything thing else to add?
Please complete this form to the best of your ability so we can determine the proper evalautions to administer. We will be in contact within one business day to schedule an evaluation.
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