Insurance & Therapy History

Check boxes or use short answers. Skip what does not apply; "not sure" is okay.

PROTOTYPE ONLY — DO NOT ENTER REAL PATIENT OR MEDICAL INFORMATION.

Insurance & Billing

Payment type *

Insurance.Self-pay.Other:

Billing Contact (if different from above)

Name

Phone

Billing address

Referral Source & Primary Care

Referred by

Primary care provider (name)

Primary care provider phone

Therapy & School Supports

Has your child received any of the following services? Check all that apply.

What helped most

School / childcare name

Grade / program

School supports / plan

IEP504 PlanIFSPNone

Service	Past	Current
Occupational Therapy (OT)
Physical Therapy (PT)
Speech-Language Therapy (SLP)
Applied Behavior Analysis (ABA)
Feeding Therapy
Vision Therapy
Mental Health / Counseling