New Patient Intake Form | Mighty Kids Therapy

Patient Information
Patient Name *

First Name Last Name
Nickname
Date of Birth *

Month Day Year
Date Date Picker Icon
Gender *

Male Female

Address *

Street Address
Street Address Line 2
City	State
Zip Code	Country

Primary Language
Other languages spoken in the home
Referring Physician *
Phone Number

Area Code Phone Number
Pediatrician (if different from referring physician)
Phone Number

Area Code Phone Number
How did you hear about us? *

Parent/Guardian Information
Parent Guardian 1 *

First Name Last Name
Relationship to Child *
Date of Birth *

Month Day Year
Date Date Picker Icon
Email Address
Phone Number *

Area Code Phone Number
Address Same as Patient? *

Yes No

Address

Street Address
Street Address Line 2
City	State
Zip Code	Country

Parent Guardian 2 *

First Name Last Name
Relationship to Child *
Phone Number *

Area Code Phone Number
Address Same as Patient?

Yes No

Address

Street Address
Street Address Line 2
City	State
Zip Code	Country

Emergency Contact
Contact Name *

First Name Last Name
Relationship to Child *
Phone Number *

Area Code Phone Number

Insurance Information
Will you be filing with your medical insurance provider? *

Yes No
Primary Insured Name *

First Name Last Name
Relationship to Patient *
Social Security Number
Insurance Company *
Provider Phone Number
Policy Number / Subscriber ID *
Group Number *
Does the patient have secondary insurance coverage?

Yes No
Insured Name *

First Name Last Name
Relationship to Patient *
Social Security Number
Insurance Company *
Provider Phone Number
Policy Number / Subscriber ID *
Group Number *

Medical History
Please list all specialists involved in your child's care
Please list all food / drug allergies *
Please list all current medications *
Please list all current or past diagnoses
Length of pregnancy:
Birth weight and length:
Type of Delivery

Vaginal Cesarean Section
Please describe any maternal complications during pregnancy or delivery.
Please describe any concerns at birth, including NICU or extended hospital stay.
Please describe any surgeries or hospitalizations, including procedure type and approximate date.
Please list any current or previous therapies including therapy type, duration, and age (ie. PT/OT/ST, ABA, school therapy, mental health)
Please describe your concerns and their approximate date of onset *
Please indicate the approximate age (in months) in which your child met the following developmental milestones:
Rolling
Sitting unsupported
Crawling
Walking
Running
Jumping
Babbling
First word
Putting two words together
Please describe the frequency at which your child attends school/daycare.
Name of School
Grade Level
Please describe any school accommodations or supports your child receives.